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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)


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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"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


    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


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


    Delayed physical complications of FGM/C.

    System affected

    Delayed complication


    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


    Fecal incontinence due to rectal sphincter injury18


    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.


    Obstetric complications of FGM/C.

    Victim of complication

    Timing of complication



    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


    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



    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.


    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


    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.


    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.


    Social complications of FGM/C.

    Party afflicted


    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.


    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.


      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.


        • 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.


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



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