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Facts about Female Genital Cutting for Health Care Providers
What is Female Genital Cutting (FGC)?
Female genital cutting (FGC), sometimes called female circumcision or female genital mutilation, means cutting, removing, or sewing closed all or part of a girl’s or woman’s external genitals for no medical reason. FGC is sometimes incorrectly identified as a religious practice- it is not. However, it is often a part of the culture in countries where it is practiced. FGC has no health benefits and can cause long-term health problems. FGC is against the law in Michigan.
Type 1: Partial or total removal of the clitoris or “clitoridectomy”.
Type 2: Partial or total removal of the clitoris and the labia or excision.
Type 3: Sewing the labia together to make the vaginal opening smaller or infibulation. The clitoris may be left in place.
Type 4: All other harm to the female genitalia for nonmedical purposes including pricking, piercing, cutting, scraping and cauterization.
Visit AAP for figures that depict FGC.See American Academy of Pediatrics (2010).Policy Statement – Ritual Genital Cutting of Female Minors.” Pediatrics, Vol 125, doi:10.1542/peds.2010-0187.
- Worldwide more than 3 million girls are estimated to be at risk for FGC annually. Procedures are mostly carried out on young girls sometime between infancy and adolescence, and occasionally on adult women.
- More than 200 million girls and women alive today have been cut in 30 countries in Africa, the Middle East and Asia where FGC is concentrated.
- The practice is most common in the western, eastern, and north-eastern regions of Africa, in some countries in the Middle East and Asia, as well as among migrants from these areas.
- Some immigrant families in the U.S. from these countries also practice FGC or may send their daughters back to their family homeland for FGC. Other immigrant families stop practicing FGC once they are in the United States.
Factors that might indicate risk for FGC
- a girl’s or woman’s community or country of origin
- a girl’s mother, sibling or other relatives have undergone FGC
- a girl’s father comes from a community known to practice FGC
- a family believes FGC is important to cultural or religious identity
- elders hold strong influence in child rearing practices
- a girl tells a professional that she is to have a ‘special procedure’ or to attend a special occasion to ‘become a woman’
- a girl talks about a long holiday to a country where the practice is prevalent
- a parent or family member expresses concern that FGC may carried our on the girl
Indications that a girl or woman has been subjected to FGC
- have difficulty walking, standing or sitting
- spend longer in the bathroom or toilet
- appear withdrawn, anxious or depressed
- have unusual behavior after an absence from school or college
- be particularly reluctant to undergo normal medical examinations
- ask for help but may not be explicit about the problem
- a girl or woman or family member tells a professional that FGC has taken place
- a girl or woman has frequent urinary, menstrual or stomach problems
- a girl avoids physical exercise or asks to be excused from physical education
- there are prolonged or repeated absences from school or college
- a girl talks about pain or discomfort between her legs
FGC can cause short term and long term consequences for girls and women.
- Severe pain
- Excessive bleeding
- Genital tissue swelling
- Infections (e.g. tetanus)
- Urinary problems
- Wound healing problems
- Injury to surrounding genital tissue
Long Term Consequences
- Urinary problems (painful urination, Urinary Tract Infections)
- Vaginal problems (discharge, itching, bacterial vaginosis, other infections)
- Menstrual problems (painful menses, difficulty passing menstrual blood)
- Sexual problems (pain during intercourse, decreased satisfaction)
- Increased risk of childbirth complications (difficult delivery, excessive bleeding, Cesarean Section, need to resuscitate the baby, newborn death)
- Scar tissue and keloid
Psychological consequences for undergoing or resisting FGC
- Feelings of loss of trust and betrayal
- Post-traumatic stress
- Depression and suicidal ideation
- Sexual fears and/or decreased sexual pleasure
- Social rejection and shame for “uncleanliness”
- May be at risk for honor violence or abuse
- Provide accurate and clear information to patients
- Refuse to perform FGC when asked.
- Communicate with cultural sensitivity
- Understand your obligations under the law.
- Learn strategies for working with at risk and affected individuals and communities.
- Treat the health conditions that may affect women with FGC
- Gynecological complications (e.g. menstrual problems, pelvic pain)
- Obstetric complications (e.g. difficult labor)
- Mental health disorders (e.g. depression, anxiety)
- Sexual dysfunctions (e.g. painful intercourse)
- Refer to local or national support organizations, including:
Women who have had FCG may be at risk for problems during and after childbirth. Risks include:
- longer labor and cesarean section birth.
- excessive bleeding after childbirth
- urine retention
- psychological problems if childbirth was difficult
No special care is necessary for women with uncomplicated and well-healed Type 1 or 2 FGC. If a Type 3 infibulation is present, then reopening of the stitched or narrowed vaginal opening (defibulation) is necessary.
If the woman presents while in labor, defibulation should be done during the second stage of labor, with a low-presenting part. If a woman requests restitching of the opening (re-infibulation) following childbirth, follow the counseling recommendations below, and explain why it is inadvisable to recreate the urethral/vaginal obstruction.
Also, discuss the advantages of defibulation, including ease with sexual intercourse and future childbearing.
- Create a welcoming environment
- Stay open to other health issues
- Remember that FGC is only one aspect of the girl’s or woman’s life
- Use appropriate language and terminology
- Ensure privacy and confidentiality
- Pay attention to your body language
- Use a professional yet friendly tone
- Listen attentively and allow the woman to speak
- Pay attention to parental attitudes
- Do not judge the woman or her culture of origin
- Show cultural awareness and respect
Different communities and cultures have different reasons for practicing FGC. Social acceptability is the most common reason. Families often feel pressure to have their daughter cut so she is accepted by their community. Other reasons may include:
- The desire to ensure a woman remains a virgin until marriage. Parents believe FGC is in the child's best interest and therefore is an expression of love.
- Rite of passage. In some countries, FGC is a part of the ritual that a girl goes through to be considered a woman
- Belief that FGC increases sexual pleasure for the man.
- Hygiene. Some communities believe that the external female genitals that are cut (the clitoris or the labia or both) are unclean.
- Condition of marriage. In some countries, a girl or woman is cut in order to be considered suitable for marriage.
- Religious duty, although no religion’s holy texts require FGC.
The World Health Organization (WHO) considers FGC a human rights violation because:
- It violates the rights to health and bodily integrity
- Is a form of violence and torture against women
- Violates the rights of children who undergo the practice without consent.
Because of this many countries have made laws banning the practice of FGC.
FGC is in the Public Health Code 333.9159, added effective October 9, 2017 The laws:
- Prohibit FGM/C on minors;
- Allow exceptions for necessary medical procedures;
- Apply to parents/guardians who facilitate as well as the individual who performs the procedure;
- Prohibit travel outside the state for the purpose of FGC/M;
- Exclude cultural/ritual reasons and/or consent as a defense;
- Provide a civil cause of action by the victim for physical and emotional damages until the victim reaches age 28;
- Provide for a felony sentence of up to 15 years imprisonment; and
- Provide a basis for termination of parental rights.
Depending on the facts and evidence in each specific case, FGC may amount to parental child abuse or neglect under the Child Protection Law.
For more information, review the Michigan Compiled Laws, www.legislature.mi.gov
- American College of Obstetricians and Gynecologists
- World Health Organization
- Office of Women’s Health US Department of Health and Human Services
- The Truth About Female Genital Mutilation
- FGM Among Us
- U.S. Genital Mutilation Victims: It Happens Here
- American Woman Who Underwent Female Genital Mutilation Comes Forward to Help Others
- How I Survived Female Genital Mutilation
Professional references for FGC
- American Academy of Pediatrics (2010). Policy Statement – Ritual Genital Cutting of Female Minors. Pediatrics, Vol 125, No 5. doi:10.1542/peds.2010-0187
- American Academy of Family Physicians (n.d.) Female Genital Mutilation
- American College of Nurse-Midwives Position Statement (2017). Female Genital Mutilation/Cutting
- Milken Institute School of Public Health, The George Washington University. FGC/M Health Care Provider Toolkit
- Nawal, N., Lalonde, A., ACOG Task Force on Female Circumcision/Female Genital Mutilation, American College of Obstetricians and Gynecologists, Women’s Health Care Physicians. (2007) Female genital cutting: clinical management of circumcised women. Washington D.C. : American College of Obstetricians and Gynecologists, Women’s Health Care Physicians.
- Toubia, N. (1999). Caring for Women with Circumcision: A Technical Manual for Health Care Providers. ISBN-10: 1893136019 Publisher: Research Action & Information
- World Health Organization (2018). Care of women and girls living with female genital mutilation: a clinical handbook. Geneva: World Health Organization. License: CC BY-NC-SA 3.0 IGO
- WHO Guidelines for the Management of Health Complications of Female Genital Mutilation (2016)
- World Health Organization, Sexual and Reproductive Health
- Addressing Female Genital Mutilation/Cutting: A Training Curriculum for Law Enforcement, Educators and Service Providers
Michigan Penal Code Sections
- 1931 PA 328
- MCL 750 136 & MCL 750 136a
- 2017 PA 76, MCL 600 5851
- 2017 PA 78, MCL 600 2978
- 2017 PA 77, MCL 333 9159
- 2017 PA 193, MCL 712A 19b
- Child Protection Laws, MCL 722 621
- Female Genital Cutting: A Fact Sheet from the Office of Women’s Health; U.S. Dept. of Health & Human Services, www.womenshealth.gov/a-z-topics/female-genital-cutting; retrieved January 2018
- Khatna, Khafz or Female Genital Cutting; Sahiyo, www.sahiyo.com; retrieved April 2018.
- What Is Female Genital Mutilation (FGM?); Forward Youth; www.forwardyouth.org.uk; retrieved April 2018.
- Female Genital Mutilation Fact Sheet; World Health Organization (WHO); www.who.int/news-room/fact-sheets/detail/female-genital-mutilation; retrieved September 2017.
- Michigan Compiled Laws; www.legislature.mi.gov retrieved October 2017.