WHO releases guidelines on the Management of Health Complications from Female Genital Mutilation (16 May 2016)

The World Health Organization (WHO) has released a new set of guidelines for the management of health complications from Female Genital Mutilation (FGM).

Background Information:

What is female genital mutilation (FGM)?

FGM refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for cultural or other non-medical reasons.

It affects more than 200 million girls and women worldwide.

Why is FGM performed?

In every society in which it is practiced, female genital mutilation is a manifestation of deeply entrenched gender inequality. Where it is widely practiced, FGM is supported by both men and women, usually without question, and anyone that does not follow the norm may face condemnation, harassment and ostracism. It may be difficult for families to abandon the practice without support from the wider community. In fact, it is often practiced even when it is known to inflict harm upon girls because the perceived social benefits of the practice are deemed higher than its disadvantages.

The reasons given for practicing FGM fall generally into five categories:

Psychosexual reasons: FGM is carried out as a way to control women’s sexuality, which is sometimes said to be insatiable if parts of the genitalia, especially the clitoris, are not removed. It is thought to ensure virginity before marriage and fidelity afterward, and to increase male sexual pleasure.
Sociological and cultural reasons: FGM is seen as part of a girl’s initiation into womanhood and as an intrinsic part of a community’s cultural heritage. Sometimes myths about female genitalia (e.g., that an uncut clitoris will grow to the size of a penis, or that FGM will enhance fertility or promote child survival) perpetuate the practice.
Hygiene and aesthetic reasons: In some communities, the external female genitalia are considered dirty and ugly and are removed, ostensibly to promote hygiene and aesthetic appeal.
Religious reasons: Although FGM is not endorsed by either Islam or by Christianity, supposed religious doctrine is often used to justify the practice.
Socio-economic factors: In many communities, FGM is a prerequisite for marriage. Where women are largely dependent on men, economic necessity can be a major driver of the procedure. FGM sometimes is a prerequisite for the right to inherit. It may also be a major income source for practitioners.

Glossary of terms used:

Incision refers to making cuts in the clitoris or cutting free the clitoral prepuce, but it also relates to incisions made in the vaginal wall and to incision of the perineum and the symphysis.

Infibulation (Type III FGM): Narrowing of the vaginal orifice with a covering seal. The seal is formed by cutting and re-positioning the labia minora and/or the labia majora. This can take place with or without removal of the clitoris.

Deinfibulation refers to the practice of cutting open a woman who has been infibulated to allow intercourse or to facilitate childbirth.

Reinfibulation is the practice of sewing the external labia back together after deinfibulation.

Medicalization of FGM/ Medicalized FGM refers to performance of FGM by trained health-care professionals.

Key Recommendations and best practice statements:

1. Deinfibulation:

Deinfibulation is recommended for preventing and treating obstetric complications in women living with type III FGM (strong recommendation; very low-quality evidence).
Either antepartum or intrapartum deinfibulation is recommended to facilitate childbirth in women living with type III FGM (conditional recommendation; very low-quality evidence).
Deinfibulation is recommended for preventing and treating urologic complications – specifically recurrent urinary tract infections and urinary retention – in girls and women living with type III FGM (strong recommendation; no direct evidence).
Girls and women who are candidates for deinfibulation should receive adequate preoperative briefing (Best practice statement).
Girls and women undergoing deinfibulation should be offered local anaesthesia (Best practice statement)

2. Mental Health:

Cognitive behavioural therapy (CBT) should be considered for girls and women living with FGM who are experiencing symptoms consistent with anxiety disorders, depression or post-traumatic stress disorder (PTSD) (conditional recommendation; no direct evidence).
Psychological support should be available for girls and women who will receive or have received any surgical intervention to correct health complications of FGM (Best practice statement).

3. Female sexual health:

Sexual counselling is recommended for preventing or treating female sexual dysfunction among women living with FGM (conditional recommendation; no direct evidence).

4. Information and Education:

Information, education and communication (IEC)4 interventions regarding FGM and women’s health should be provided to girls and women living with any type of FGM (Best practice statement).
Health education5 information on deinfibulation should be provided to girls and women living with type III FGM (Best practice statement).
Health-care providers have the responsibility to convey accurate and clear information, using language and methods that can be readily understood by clients (Best practice statement).
Information regarding different types of FGM and the associated respective immediate and long-term health risks should be provided to health-care providers who care for girls and women living with FGM (Best practice statement).
Information about FGM delivered to health workers should clearly convey the message that medicalization is unacceptable (Best practice statement).