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This chapter should be cited as follows:
Koigi PK, Kihara AB, Glob. libr. women's med.,
ISSN: 1756-2228; DOI 10.3843/GLOWM.417813

The Continuous Textbook of Women’s Medicine SeriesGynecology Module

Volume 1

Female genital mutilation

Volume Editor: Professor Anne-Beatrice Kihara, University of Nairobi, Kenya,
President-elect. The International Federation of Gynecology and Obestetrics FIGO
President, African Federation of Obstetricians and Gynecologists (AFOG)

Chapter

Complications of Female Genital Mutilation/Cutting

First published: July 2022

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By completing 4 multiple-choice questions (randomly selected) after studying this chapter readers can qualify for Continuing Professional Development awards from FIGO plus a Study Completion Certificate from GLOWM
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INTRODUCTION

"Female genital mutilation/cutting (FGM/C)" refers to all procedures that involve partial or total non-medical excision or injury of the female external genitalia. It has no health benefits, is typically culturally driven, and is associated with a kaleidoscope of adverse health consequences. In addition to these consequences, FGM/C directly violates multiple human rights.1

Typically, the adverse effects of FGM/C increase in direct proportion with the extent of the procedure.2 The complications of FGM/C are typically considered from two main perspectives:

    • According to the timing of their occurrence: immediate and delayed.2,3
    • According to the dimensional function affected: obstetric; sexual; psychological; social; and socioeconomic.1

    IMMEDIATE COMPLICATIONS OF FGM/C

    The immediate complications associated with FGM/C include the following: pain;4 genital swelling; bleeding; local abscess formation; rectal injury;1 genital ulceration;5 shock (hemorrhagic, neurogenic and/or septic);1,3 acute urinary retention with dysuria;6 dislocations and fractures (from being restrained);3 and death.7

    DELAYED PHYSICAL COMPLICATIONS OF FGM/C

    The delayed complications of FGM/C are those that develop after a time lag. They are shown in Table 1.

    1

    Delayed physical complications of FGM/C.

    System affected

    Delayed complication

    General

    Increased incidence of human immunodeficiency virus (HIV), Chlamydia trachomatis, Clostridium tetani, Neisseria gonorrhoea, Treponema pallidum, Candida albicans, Trichomonas vaginalis, Pseudomonas pyocyanea, Staphylococcus aureus, herpes simplex virus (HSV) type 2, hepatitis B and hepatitis C infections1,5,8

    Reproductive tract

    Chronic and recurrent genital tract infections, including bacterial vaginosis9

    Chronic pelvic pain4

    Menstrual problems: dysmenorrhea, hematocolpos3

    Vulvodynia and/or clitorodynia1

    Keloid and synechia formation due to poor healing10

    Para-clitoral cyst11 and atheroma formation,12 clitoral neuroma formation and formation of clitoral stones13,14,15

    Urinary tract

    Renal failure6

    Urinary incontinence due to urethral damage6

    Lower urinary tract symptoms: nocturia, intermittency, incomplete voiding,6,16,17 and dysuria4

    Gastrointestinal

    Fecal incontinence due to rectal sphincter injury18

    OBSTETRIC COMPLICATIONS OF FGM/C

    The experience of FGM/C makes the navigation of the journey of pregnancy objectively more precarious, both during and after the pregnancy, for both the mother and the fetus. These complications are shown in Table 2, with an emphasis on the victim and timing of the complications.

    2

    Obstetric complications of FGM/C.

    Victim of complication

    Timing of complication

    Complication

    Maternal19,20,21,22,23

    Early pregnancy

    Higher risk of miscarriage24

    Throughout pregnancy

    Delayed initiation of antenatal care seeking and lower overall frequency of clinic attendance25

    Recurrent urinary tract infections during pregnancy24

    Higher risk of preterm labor and delivery26

    Intrapartum

    Lower skilled birth attendance27

    Difficulty in performing vaginal examinations,2 hence delaying diagnosis and treatment26

    Possible need for defibulation to facilitate delivery28,29

    Need for instrumental and operative delivery (cesarean section)30

    Labor dystocia4

    Uterine rupture30

    Need for episiotomy4,31

    Primary post-partum hemorrhage31

    Obstetric lacerations,4,32 including anal sphincter injury33,34

    Longer duration of hospital admission

    Independent association with eclampsia35

    Puerperium and beyond

    Puerperal sepsis

    Pelvic floor damage36

    Obstetric fistula formation (RVF and VVF)37

    Neonatal10,19,38,39

    N/A

    Low Apgar scores32

    Low birth weight

    Stillbirth or early neonatal death40

    Hypoxic ischemic encephalopathy

    Need for neonatal resuscitation

    N/A, not applicable; RVF, rectovaginal fistula; VVF, vesicovaginal fistula.

    SEXUAL COMPLICATIONS OF FGM/C

    There are multiple sexual complications associated with female genital mutilation/cutting. These complications are more often experienced by those who have undergone type III FGM/C. They include the following: failed marital consummation;41 reduced sexual desire and arousal;42 reduce orgasmic frequency;43 development of superficial and/or deep dyspareunia;4 decreased sexual satisfaction; reduced lubrication during sexual intercourse; and infertility (due to recurrent and chronic genital infections).2,3,44,45 Perhaps an even more frustrating aspect of the sexual complications of FGM/C is that defibulation may result in worsening of sexual experience in up to 1/5 of its subscribers.46

    PSYCHOLOGICAL COMPLICATIONS OF FGM/C

    Over and above the physical trauma incurred from the infliction of damage by this untoward procedure, FGM/C is associated with multiple psychological complications, viz., post-traumatic stress disorder (PTSD); impaired memory function; anxiety disorders; depression; neuroses; psychosis; psychosomatic diseases;1,2,3,47,48 and distorted body image.27 In congruence with the physical complications, the psychological complications increase in severity with the extent of the FGM/C.49

    Amongst men with partners who have undergone FGM/C, there have been reports of difficulty in vaginal penetration, infliction of penile wounds, development of penile infections, and the development of psychosexual problems, including reduced sexual satisfaction.40

    Given the fact that the cultural contexts that perpetuate this practice are also typically characterized by low mental health-seeking behavior,50 addressing the psychological wounds and scars that these women bear remains an uphill task.

    SOCIAL COMPLICATIONS OF FGM/C

    The social complications of FGM/C may span to include those that directly afflict the woman, those that afflict her immediate family; and those that afflict the society at large. These complications are shown in Table 3.

    3

    Social complications of FGM/C.

    Party afflicted

    Complication

    The woman

    Irritability and persistent hostility48

    Reduction in quality of life3

    Reduction in length of life5

    The couple

    Marital conflict due to dyspareunia51

    Increased risk of intimate partner violence (physical, sexual, and emotional)52

    Reduced quality of communication within the couple40

    The children of the woman

    Increased risk of FGM/C being performed on her children51,53,54,55

    The woman and other women in the society

    Perpetuation of female gender oppression51,56 due to conformation to subjective cultural norms53 intending to reduce female sexuality57

    Poor health-seeking behavior due to cultural deference rules that silence raising these concerns during consultations58

    FGM/C, female genital mutilation/cutting.

    SOCIOECONOMIC COMPLICATIONS OF FGM/C

    There are three main recognized socioeconomic consequences of FGM/C:5

      • Increased economic burden on the individual, society, and health system.
      • Increased social burden of disability on women and on the community.
      • Reduced ability of women to participate in economic and social activities.

      A NEW INTEGRATIVE APPROACH TOWARDS FGM/C COMPLICATIONS

      In order to effectively address the subject of FGM from a public health angle, it may be possible to introduce a third integrative perspective, which will enhance the capacity to contextualize and thus address the complications.

      Considering FGM/C complications according to the sequence of development of the complications in relation to the procedure, with consideration of the parties afflicted. This would result in the categorization of the complications into the following:

        • Primary: direct complications associated with the procedure (Immediate) that afflict the patient.
        • Secondary: complications that follow the procedure but may be delayed and may afflict other systems other than the reproductive system. These include obstetric complications that affect the neonate.
        • Tertiary: complications that afflict the immediate family members of the women that undergo FGM/C.
        • Quaternary: complications that afflict the society at large as a long-term consequence of the suffering of the women and their families. This includes the professional aspect that seeks to medicalize FGM/C.

        PRACTICE RECOMMENDATIONS

        • Female genital mutilation/cutting has no health benefits.
        • Complications of female genital mutilation/cutting may be as follows: immediate; delayed physical; obstetric; sexual; psychological; social; and socioeconomic.
        • Infibulation complicates obstetric examination.
        • Defibulation and episiotomy may be required to facilitate delivery due to vaginal and perineal fibrosis.
        • Offer clinical and mental health attention to those who have undergone female genital mutilation/cutting, as the cultural context is also associated with reduced health-seeking behavior.
        • Multidisciplinary management is vital in ensuring that the kaleidoscope of complications resulting from female genital mutilation/cutting are conclusively addressed.


        CONFLICTS OF INTEREST

        The author(s) of this chapter declare that they have no interests that conflict with the contents of the chapter.

        REFERENCES

        1

        World Health Organization. Background. In: Say L. (ed.) WHO guidelines on the management of health complications from female genital mutilation. Geneva: WHO Document Production Services, 2016:1–11.

        2

        Utz-Billing I, Kentenich H. Female genital mutilation: An injury, physical and mental harm. J Psychosom Obstet Gynecol 2008;29(4):225–9.

        3

        Siddig I. Female genital mutilation: What do we know so far? Br J Nurs 2016;25(16):912–6.

        4

        Lurie JM, Weidman A, Huynh S, et al. Painful gynecologic and obstetric complications of female genital mutilation/cutting: A systematic review and meta-analysis. PLoS Med 2020;17(3).

        5

        Refaei M, Aghababaei S, Pourreza A, et al. Socioeconomic and reproductive health outcomes of female genital mutilation. Arch Iran Med 2016;19(11):805–11.

        6

        Clarke E. Female genital mutilation: a urology focus. Bristish J Nurs 2016;25(18):1022–8.

        7

        Thomas J. Female genital mutilation complications lead to lost lives and high costs. Int Fam Plan Perspect 2010;36(3).

        8

        Iavazzo C, Sardi TA, Gkegkes ID. Female genital mutilation and infections: A systematic review of the clinical evidence. Arch Gynecol Obstet 2013;287(6):1137–49.

        9

        Berg RC, Underland V, Odgaard-Jensen J, et al. Effects of female genital cutting on physical health outcomes: A systematic review and meta-analysis. BMJ Open 2014;4(11):1–12.

        10

        Kaplan A, Forbes M, Bonhoure I, et al. Female genital mutilation/cutting in The Gambia: Long-term health consequences and complications during delivery and for the newborn. Int J Womens Health 2013;5(1):323–31.

        11

        Kaur-Desai T, Makris A. Massive epidermal vulval cyst: An unusual late complication of female genital mutilation. BMJ Case Rep 2017.

        12

        Schöller D, Reisenauer C. Genital epidermal horn cyst (atheroma) after female genital mutilation WHO type III b. Arch Gynecol Obstet [Internet] 2018;297(4):821–2. Available from: https://doi.org/10.1007/s00404-018-4707-7.

        13

        Zoorob D, Kristinsdottir K, Klein T, et al. Symptomatic Clitoral Neuroma within an Epidermal Inclusion Cyst at the Site of Prior Female Genital Cutting. Case Rep Obstet Gynecol [Internet] 2019:1–3. Available from: https://doi.org/10.1155/2019/5347873.

        14

        Al-Hussaini TK. Clitoral stones are a rare complication of female genital mutilation. Int J Gynecol Obstet 2016;135:225–7.

        15

        Abdulcadir J, Tille JC, Petignat P. Management of painful clitoral neuroma after female genital mutilation/cutting. Reprod Health 2017;14(1):1–7.

        16

        Teufel K, Dörfler DM. Female genital circumcision/mutilation: Implications for female urogynaecological health. Int Urogynecol J Pelvic Floor Dysfunct 2013;24(12):2021–7.

        17

        Amin MM, Rasheed S, Salem E. Lower urinary tract symptoms following female genital mutilation. Int J Gynecol Obstet 2013;123(1):21–3.

        18

        Lopez HN, Focseneanu MA, Merritt DF. Genital injuries acute evaluation and management. Best Pract Res Clin Obstet Gynaecol [Internet] 2018;48:28–39. Available from: https://doi.org/10.1016/j.bpobgyn.2017.09.009.

        19

        Sylla F, Moreau C, Andro A. A systematic review and meta-analysis of the consequences of female genital mutilation on maternal and perinatal health outcomes in European and African countries. BMJ Glob Heal 2020;5(12):1–14.

        20

        Rashid M, Rashid MH. Review: Obstetric management of women with female genital mutilation. Obstet Gynaecol [Internet] 2007;9:95–101. Available from: www.rcog.org.uk/togonline.

        21

        Berg RC, Underland V. The Obstetric Consequences of Female Genital Mutilation/Cutting: A Systematic Review and Meta-Analysis. Obstet Gynecol Int 2013;2013:1–15.

        22

        Muchene KW, Mageto IG, Cheptum JJ. Knowledge and Attitude on Obstetric Effects of Female Genital Mutilation among Maasai Women in Maternity Ward at Loitokitok Sub-County Hospital, Kenya. Obstet Gynecol Int 2018;2018:1–5.

        23

        Larsen U, Okonofua FE. Female circumcision and obstetric complications. Int J Gynecol Obstet 2002;77:255–65.

        24

        Gayle C, Rymer J. Female genital mutilation and pregnancy: associated Risks. Br J Nurs 2016;27(17):978–83.

        25

        Antabe R, Sano Y, Anfaara FW, et al. Antenatal Care Utilization and Female Genital Mutilation in Kenya. Sex Cult 2019;23(3):705–17.

        26

        Gayle C, Rymer J. Female genital mutilation and pregnancy: Associated risks. Br J Nurs 2016;25(17):978–83.

        27

        Esu E, Okoye I, Arikpo I, et al. Providing information to improve body image and care-seeking behavior of women and girls living with female genital mutilation: A systematic review and meta-analysis. Int J Gynaecol Obstet 2017;136:72–8.

        28

        Esu E, Udo A, Okusanya BO, et al. Antepartum or intrapartum deinfibulation for childbirth in women with type III female genital mutilation: A systematic review and meta-analysis. Int J Gynaecol Obstet 2017;136:21–9.

        29

        Abdulcadir J, Dugerdil A, Yaron M, et al. Obstetric care of women with female genital mutilation attending a specialized clinic in a tertiary center. Int J Gynecol Obstet 2016;132(2):174–8.

        30

        Rodriguez MI, Say L, Abdulcadir J, et al. Clinical indications for cesarean delivery among women living with female genital mutilation. Int J Gynecol Obstet 2017;139(1):21–7.

        31

        Balachandran AA, Duvalla S, Sultan AH, et al. Are obstetric outcomes affected by female genital mutilation? Int Urogynecol J 2018;29(3):339–44.

        32

        Gebremicheal K, Alemseged F, Ewunetu H, et al. Sequela of female genital mutilation on birth outcomes in Jijiga town, Ethiopian Somali region: A prospective cohort study. BMC Pregnancy Childbirth 2018;18(1).

        33

        Rodriguez MI, Seuc A, Say L, et al. Episiotomy and obstetric outcomes among women living with type 3 female genital mutilation: a secondary analysis. Reprod Health [Internet] 2016;13(1):1–7. Available from: http://dx.doi.org/10.1186/s12978-016-0242-9.

        34

        Berggren V, Gottvall K, Isman E, et al. Infibulated women have an increased risk of anal sphincter tears at delivery: a population-based Swedish register study of 250,000 births. Acta Obstet Gynecol Scand 2013;92(1):101–8.

        35

        Bellizzi S, Say L, Rashidian A, et al. Is female genital mutilation associated with eclampsia? Evidence from a nationally representative survey data. Reprod Health 2020;17(1):1–6.

        36

        Binkova A, Uebelhart M, Dällenbach P, et al. A cross-sectional study on pelvic floor symptoms in women living with Female Genital Mutilation/Cutting. Reprod Health [Internet] 2021;18(1):1–12. Available from: https://doi.org/10.1186/s12978-021-01097-9.

        37

        Mwanri L, Gatwiri GJ. Injured bodies, damaged lives: Experiences and narratives of Kenyan women with obstetric fistula and Female Genital Mutilation/Cutting. Reprod Health 2017;14(1):1–11.

        38

        Suleiman IR, Maro E, Shayo BC, et al. Trend in female genital mutilation and its associated adverse birth outcomes: A 10-year retrospective birth registry study in Northern Tanzania. PLoS One [Internet] 2021;16:1–13. Available from: http://dx.doi.org/10.1371/journal.pone.0244888.

        39

        Frega A, Puzio G, Maniglio P, et al. Obstetric and neonatal outcomes of women with FGM I and II in San Camillo Hospital, Burkina Faso. Arch Gynecol Obstet [Internet] 2013[cited 2021 Dec 20];288(3):513–9. Available from: https://pubmed.ncbi.nlm.nih.gov/23471548/.

        40

        Varol N, Fraser IS, Ng CHM, et al. Female genital mutilation/cutting – Towards abandonment of a harmful cultural practice. Aust New Zeal J Obstet Gynaecol 2014;54(5):400–5.

        41

        Dilbaz B, İflazoğlu N, Tanın SA. An overview of female genital mutilation. Turkish J Obstet Gynecol 2019;16(2):129–32.

        42

        Yassin K, Idris HA, Ali AA. Characteristics of female sexual dysfunctions and obstetric complications related to female genital mutilation in Omdurman maternity hospital, Sudan. Reprod Health 2018;15(1):4–8.

        43

        Catania L, Abdulcadir O, Puppo V, et al. Pleasure and orgasm in women with female genital mutilation/cutting (FGM/C). J Sex Med 2007;4(6):1666–78.

        44

        Andersson SHA, Rymer J, Joyce DW, et al. Sexual quality of life in women who have undergone female genital mutilation: a case-control study. Br J Obstet Gynecol [Internet] 2012;119(13):1606–11. Available from: https://pubmed.ncbi.nlm.nih.gov/23046483/.

        45

        Esho T, Kimani S, Nyamongo I, et al. The “heat” goes away: Sexual disorders of married women with female genital mutilation/cutting in Kenya. Reprod Health 2017;14(1):1–9.

        46

        Berg RC, Taraldsen S, Said MA, et al. The effectiveness of surgical interventions for women with FGM/C: a systematic review. BJOG An Int J Obstet Gynaecol 2018;125(3):278–87.

        47

        Piroozi B, Alinia C, Safari H, et al. Effect of female genital mutilation on mental health: a case–control study. Eur J Contracept Reprod Heal Care 2020;25(1):33–6.

        48

        Ahmed MR, Shaaban MM, Meky HK, et al. Psychological impact of female genital mutilation among adolescent Egyptian girls: a cross-sectional study. Eur J Contracept Reprod Heal Care 2017;22(4):280–5.

        49

        Köbach A, Ruf-Leuschner M, Elbert T. Psychopathological sequelae of female genital mutilation and their neuroendocrinological associations. BMC Psychiatry 2018;18(1):1–12.

        50

        Lien IL, Hertzberg CK. A system analysis of the mental health services in Norway and its availability to women with female genital mutilation. PLoS One [Internet] 2020;15:1–19. Available from: http://dx.doi.org/10.1371/journal.pone.0241194.

        51

        Youssouf S. Female genital mutilations-A testimony. Eur J Contracept Reprod Heal Care 2013;18(1):5–9.

        52

        Salihu HM, August EM, Salemi JL, et al. The association between female genital mutilation and intimate partner violence. Br J Obstet Gynecol [Internet] 2012;119(13):1597–605. Available from: https://pubmed.ncbi.nlm.nih.gov/22925207/.

        53

        Pashaei T, Ponnet K, Moeeni M, et al. Daughters at risk of female genital mutilation: Examining the determinants of mothers’ intentions to allow their daughters to undergo female genital mutilation. PLoS One 2016;11(3):1–12.

        54

        Dalal K, Lawoko S, Jansson B. Women’s attitudes towards discontinuation of female genital mutilation in Egypt. J Inj Violence Res 2010;2(1):41–7.

        55

        Adinew YM, Mekete BT. I knew how it feels but couldn’t save my daughter; Testimony of an Ethiopian mother on female genital mutilation/cutting. Reprod Health 2017;14(1):1–5.

        56

        Wade L. Defining gendered oppression in U.S. newspapers: The strategic value of “female Genital Mutilationg”. Gend Soc 2009;23(3):293–314.

        57

        Sakeah E, Debpuur C, Aborigo RA, et al. Persistent female genital mutilation despite its illegality: Narratives from women and men in northern Ghana. PLoS One 2019;14(4):1–14.

        58

        Kimani S, Kabiru CW, Muteshi J, et al. Exploring barriers to seeking health care among Kenyan Somali women with female genital mutilation: A qualitative study. BMC Int Health Hum Rights 2020;20(1):1–12.

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