- Email: [email protected]
Female circumcision
Female Circumcision By Paul Brisson, Haroon Patel, and Neil Feins Boston, Massachusetts
Female circumcision, more accurately known as female genital mutilation, is still a common practice in parts of Africa. This ritual genital operation can involve partial or complete excision of the clitoris and labia minora as well as infibulation (labial fusion). The case reported here involves a 16-year-old African girl with a complication of this mutilating procedure.
J Pediatr Surg 36:1068-1069. Copyright Saunders Company.
©
2001 by W.B.
INDEX WORDS: Female circumcision, female genital mutilation, clitoridectomy, infibulation.
F
EMALE CIRCUMCISION, also known as female genital mutilation, is still a common practice in parts of Africa and small communities in the Middle East and Asia. It is estimated that 100 million women have undergone this procedure and that 4 to 5 million are now performed annually.1 This ritual operation can involve the partial or complete excision of the clitoris and labia minora as well as infibulation, ie, labial fusion.2 The persistence of this practice is related to cultural identity and marriagability. This mutilating procedure can lead to early and delayed complications as reported here. CASE REPORT A 16-year-old African-American girl presented with painful menses. Examination of the perineum found no identifiable clitoris. The labia majora was fused with just a 1-cm opening. Urination and menstruation occurred via this small orifice (Fig 1). Anal examination was normal. We suspected that this patient might have had prior surgical treatment for ambiguous genitalia. Hormonal analysis was normal. Perinealography was obtained that showed filling of the vagina, urethra, and bladder simulating a urogenital sinus. The vagina was dilated suggesting obstruction (Fig 2). An additional in-depth social history revealed that while residing in the United States the patient’s mother arranged for her daughter to have a circumcision performed in Africa. The procedure, removal of the clitoris, labia minora, and fusion of the labia majora to cover the vagina, was performed by a local “expert” without anesthesia. We performed a deinfibulation procedure, dividing the fused labia majora, which was curative of her painful menses (Fig 3).
Fig 1. Initial physical examination shows fusion of the labia majora with a small central orifice for menstruation and urination.
From the Floating Hospital for Children, Boston, MA. Address reprint requests to Paul Brisson, MD, Schenectady Surgical Care Associates, 634 McClellan St, Suite 202, Schenectady, NY 12304. Copyright © 2001 by W.B. Saunders Company 0022-3468/01/3607-0023$35.00/0 doi:10.1053/jpsu.2001.24755
or in older girls just before marriage.2 The circumcision procedures often are performed without regard for sterility and without anesthesia.3 The surgical procedures involved are quite diverse. Toubia2 has recommended a procedure classification system that involves 4 types: type 1, clitoridectomy; type 2, clitoridectomy and partial excision of the labia minora; type 3, partial infibulation; type 4, removal of the clitoris, labia minora, and total infibulation to cover the urethra and entrance to the vagina. The Type 4 procedure leaves a very small posterior opening for urine and menstrual blood, which results in obstruction to vaginal examination, intercourse, and labor. Although not in Dr Toubia’s classification, a simpler procedure, removal of the clitoral prepuce only, analagous to the male circumcision, may be performed.4 Our patient seemed to have a type 4 procedure, although the opening was mid infibulation rather than posterior. Dr Toubia also notes that this grading system is only a guide, and that other deformities also are likely to be seen.2 Female circumcision is not universally accepted even
1068
Journal of Pediatric Surgery, Vol 36, No 7 (July), 2001: pp 1068-1069
DISCUSSION
Female circumcision or female genital mutilation is practiced in about 26 African countries. The procedure is most commonly performed on girls between the ages of 4 and 10 years, although it may be performed on infants
FEMALE CIRCUMCISION
1069
Fig 3.
Fig 2. Perinealography (A) and diagram (B) show a normal urinary bladder and obstructed vagina.
in the countries in which it is an age-old tradition.5 A number of local African groups have formed in an effort
Surgical division of the fused labia (deinfibulation).
to eliminate the practice.6 Female genital mutilation has been outlawed in 15 of the 28 countries where it exists, along with 6 European countries.7 The procedure also is punishable as child abuse in other countries.1,8 In 1993 legislation was introduced in the US House of Representatives that would prohibit genital mutilation of girls in the United States.9 That bill never made it out of committee. In 1999 a bill was introduced to the 106th Congress recommending that gender-related persecution, including female genital mutilation, may be a determining factor in an alien’s eligibility for asylum.10 The most common corrective procedure is deinfibulation such as was required in our patient. This procedure involves division of the fused labia majora with suturing of each labia for hemostasis. The American Academy of Pediatrics opposes all forms of female genital mutilation and recommends that no unnecessary procedure to alter the genitalia of female infants, girls, and adolescents be performed by its members.1 Pediatric surgeons and pediatric urologists should be aware of this practice. These surgeons may be presented with complications related to female genital mutilation, or even be requested to perform a primary ritual genital operation or subsequent reinfibulation.
REFERENCES 1. American Academy of Pediatrics, Committee on Bioethics: Female Genital Mutilation. Pediatrics 102:153-156, 1998 2. Toubia N: Female circumcision as a public health issue. N Engl J Med 331:712-715, 1994 3. NOCIRC Newsletter: Genital mutilation by any other name . . . Fall 1993, Vol 7, No 2 4. Horowitz CR, Jackson JC, Teklemariam M: Female circumcision. N Engl J Med 332:188, 1995 5. INS released woman who fled mutilation. Boston Globe, July 20, 1999
6. Schroeder P (D-Colo): Female genital mutilation—A form of child abuse. N Engl J Med 331:739-740, 1994 7. A painful tradition. Newsweek, 32-33, July 5, 1999 8. Dirie A, Lindmark G: Female circumcision in Somolia and woman’s motives. Acta Obstet Gynecol Scand; 70:581-585, 1991 9. Schroeder P: H.R. 3247: The Federal Prohibition of Female Genital Mutilation Act of 1993 10. Maloney C, McNulty M, et al: House of Representatives bill no. 1849, 1999
Female circumcision, more accurately known as female genital mutilation, is still a common practice in parts of Africa. This ritual genital operation can involve partial or complete excision of the clitoris and labia minora as well as infibulation (labial fusion). The case reported here involves a 16-year-old African girl with a complication of this mutilating procedure.
J Pediatr Surg 36:1068-1069. Copyright Saunders Company.
©
2001 by W.B.
INDEX WORDS: Female circumcision, female genital mutilation, clitoridectomy, infibulation.
F
EMALE CIRCUMCISION, also known as female genital mutilation, is still a common practice in parts of Africa and small communities in the Middle East and Asia. It is estimated that 100 million women have undergone this procedure and that 4 to 5 million are now performed annually.1 This ritual operation can involve the partial or complete excision of the clitoris and labia minora as well as infibulation, ie, labial fusion.2 The persistence of this practice is related to cultural identity and marriagability. This mutilating procedure can lead to early and delayed complications as reported here. CASE REPORT A 16-year-old African-American girl presented with painful menses. Examination of the perineum found no identifiable clitoris. The labia majora was fused with just a 1-cm opening. Urination and menstruation occurred via this small orifice (Fig 1). Anal examination was normal. We suspected that this patient might have had prior surgical treatment for ambiguous genitalia. Hormonal analysis was normal. Perinealography was obtained that showed filling of the vagina, urethra, and bladder simulating a urogenital sinus. The vagina was dilated suggesting obstruction (Fig 2). An additional in-depth social history revealed that while residing in the United States the patient’s mother arranged for her daughter to have a circumcision performed in Africa. The procedure, removal of the clitoris, labia minora, and fusion of the labia majora to cover the vagina, was performed by a local “expert” without anesthesia. We performed a deinfibulation procedure, dividing the fused labia majora, which was curative of her painful menses (Fig 3).
Fig 1. Initial physical examination shows fusion of the labia majora with a small central orifice for menstruation and urination.
From the Floating Hospital for Children, Boston, MA. Address reprint requests to Paul Brisson, MD, Schenectady Surgical Care Associates, 634 McClellan St, Suite 202, Schenectady, NY 12304. Copyright © 2001 by W.B. Saunders Company 0022-3468/01/3607-0023$35.00/0 doi:10.1053/jpsu.2001.24755
or in older girls just before marriage.2 The circumcision procedures often are performed without regard for sterility and without anesthesia.3 The surgical procedures involved are quite diverse. Toubia2 has recommended a procedure classification system that involves 4 types: type 1, clitoridectomy; type 2, clitoridectomy and partial excision of the labia minora; type 3, partial infibulation; type 4, removal of the clitoris, labia minora, and total infibulation to cover the urethra and entrance to the vagina. The Type 4 procedure leaves a very small posterior opening for urine and menstrual blood, which results in obstruction to vaginal examination, intercourse, and labor. Although not in Dr Toubia’s classification, a simpler procedure, removal of the clitoral prepuce only, analagous to the male circumcision, may be performed.4 Our patient seemed to have a type 4 procedure, although the opening was mid infibulation rather than posterior. Dr Toubia also notes that this grading system is only a guide, and that other deformities also are likely to be seen.2 Female circumcision is not universally accepted even
1068
Journal of Pediatric Surgery, Vol 36, No 7 (July), 2001: pp 1068-1069
DISCUSSION
Female circumcision or female genital mutilation is practiced in about 26 African countries. The procedure is most commonly performed on girls between the ages of 4 and 10 years, although it may be performed on infants
FEMALE CIRCUMCISION
1069
Fig 3.
Fig 2. Perinealography (A) and diagram (B) show a normal urinary bladder and obstructed vagina.
in the countries in which it is an age-old tradition.5 A number of local African groups have formed in an effort
Surgical division of the fused labia (deinfibulation).
to eliminate the practice.6 Female genital mutilation has been outlawed in 15 of the 28 countries where it exists, along with 6 European countries.7 The procedure also is punishable as child abuse in other countries.1,8 In 1993 legislation was introduced in the US House of Representatives that would prohibit genital mutilation of girls in the United States.9 That bill never made it out of committee. In 1999 a bill was introduced to the 106th Congress recommending that gender-related persecution, including female genital mutilation, may be a determining factor in an alien’s eligibility for asylum.10 The most common corrective procedure is deinfibulation such as was required in our patient. This procedure involves division of the fused labia majora with suturing of each labia for hemostasis. The American Academy of Pediatrics opposes all forms of female genital mutilation and recommends that no unnecessary procedure to alter the genitalia of female infants, girls, and adolescents be performed by its members.1 Pediatric surgeons and pediatric urologists should be aware of this practice. These surgeons may be presented with complications related to female genital mutilation, or even be requested to perform a primary ritual genital operation or subsequent reinfibulation.
REFERENCES 1. American Academy of Pediatrics, Committee on Bioethics: Female Genital Mutilation. Pediatrics 102:153-156, 1998 2. Toubia N: Female circumcision as a public health issue. N Engl J Med 331:712-715, 1994 3. NOCIRC Newsletter: Genital mutilation by any other name . . . Fall 1993, Vol 7, No 2 4. Horowitz CR, Jackson JC, Teklemariam M: Female circumcision. N Engl J Med 332:188, 1995 5. INS released woman who fled mutilation. Boston Globe, July 20, 1999
6. Schroeder P (D-Colo): Female genital mutilation—A form of child abuse. N Engl J Med 331:739-740, 1994 7. A painful tradition. Newsweek, 32-33, July 5, 1999 8. Dirie A, Lindmark G: Female circumcision in Somolia and woman’s motives. Acta Obstet Gynecol Scand; 70:581-585, 1991 9. Schroeder P: H.R. 3247: The Federal Prohibition of Female Genital Mutilation Act of 1993 10. Maloney C, McNulty M, et al: House of Representatives bill no. 1849, 1999