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An immigrant female patient came to your office for routine visit and GYN exam reveal the following.
What is the diagnosis ?
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Female genital cutting (FGC) refers to amputation of any part of the female genitalia for cultural rather than medical reasons, not including genital modification of intersexuals or gender reassignment surgery.
Most Human rights organizations in the West, Africa, and Asia consider female genital cutting rituals a violation of women's human rights. Among these groups and governments, they are regarded as unacceptable and illegal forms of body modification and mutilation of those believed to be too young or otherwise unable to give informed consent.
Although occasionally practiced by some doctors in the United States until 1958, in recent years it is only common in parts of Africa and by minority groups in some countries of the Middle East. Less frequently, it occurs among some immigrant communities in parts of Asia and the Pacific, North and Latin America, and Europe.
Opponents of these practices use the term female genital mutilation (FGM). The term female circumcision is also in common usage, though advocates of male circumcision argue that this results in unwanted associations between the two practices, while genital integrity advocates might refer to all child genital cutting as mutilation. It also should be noted that the term encompasses a wide variety of practices some of which are frequently equated directly with male circumcision, others which involve a far greater level of cutting or mutilation and others yet which involve no real cutting or mutilation.
Different forms
There are several distinct practices that are all generally referred to by this name. In particular, while female genital cutting is generally thought of in the West as involving the complete destruction of the female sexual organs in an effort to eliminate the female's sexual pleasure, in some forms female circumcision is claimed to be analogous to male circumcision, in that both procedures can involve the removal of the prepuce and the frenulum.
In other cases, the procedure has no tissue removal at all, but is simulated with a knife as part of a ceremony, or with a symbolic drop of blood released with a needle. Those that involve tissue removal are usually divided into three major types.
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Clitoridotomy
"Clitoridotomy" (which is also called "hoodectomy" as a slang term) involves the removal or splitting of the clitoral hood. The United Nations Population Fund states that this is comparable to male circumcision.[1] In the United States and other Western countries, clitoridotomy is usually performed on adult women rather than on children. It is also known as Sunna circumcision (named after the Arabic word for anything approved by Islamic law and centred in Islamic tradition). However some Muslim clergy oppose all forms of FGC. [2]
Sami A. Aldeeb Abu-Sahlieh, author of 'To Mutilate in the Name of Jehovah or Allah: Legitimization of Male and Female Circumcision' states that: "The most often mentioned narration reports a debate between Prophet Mohammed (Praise Be Upon Him) and Um Habibah (or Um 'Atiyyah). This woman, known as an exciser of female slaves, was one of a group of women who had immigrated with Mohammed (Praise Be Upon Him). Having seen her, Prophet Mohammed (Praise Be Upon Him) asked her if she kept practicing her profession. She answered affirmatively adding: 'unless it is forbidden and you order me to stop doing it'. Prophet Mohammed (Praise Be Upon Him) replied: 'Yes, it is allowed. Come closer so I can teach you: if you cut, do not overdo it (la tanhaki), because it brings more radiance to the face (ashraq) and it is more pleasant (ahza) for the husband'. According to others, he said: 'Cut slightly and do not overdo it (ashimmi wa-la tanhaki), because it is more pleasant (ahza) for the woman and better (ahab, from other sources abha) for the husband'."
Type I circumcision is defined by the World Health Organisation as clitoridotomy and perhaps excision of part or all of the clitoris (clitoridectomy; see following section). However, some authors (e.g.., Cohen) define type I as at least partial removal of the clitoris.
From the late 19th century until the 1950s, it and other more invasive procedures, including excision of the clitoris and infibulation were practiced in Western countries to control female sexuality, and were advocated in the United States by groups like the Orificial Surgery Society until 1925. According to Paige, doctors advocating or performing these procedures claimed that girls of all ages would otherwise engage in more masturbation and be "polluted" by the activity, which was referred to as "self-abuse" [3].
Through the 1950s, some doctors continued to advocate clitoridotomy for hygienic reasons or to reduce masturbation. For example, C.F. McDonald wrote in a 1958 paper titled Circumcision of the Female [4],[5], "If the male needs circumcision for cleanliness and hygiene, why not the female? I have operated on perhaps 40 patients who needed this attention." The author describes symptoms as "irritation, scratching, irritability, masturbation, frequency and urgency," and in adults, smegmaliths causing "dyspareunia and frigidity." The author then reported that a two-year old was no longer masturbating so frequently after the procedure. Of adult women, the author stated that "for the first time in their lives, sex ambition became normally satisfied." In the U.S., the last documented clitoridotomy to reduce sexual activity occurred in 1958. The procedure was performed on a 5-year-old girl, reportedly to stop her from masturbating. Justification of the procedure on hygienic grounds, or to reduce masturbation, has since declined. The view that masturbation is a cause of mental and physical illness has dissipated since the mid-20th century [6].
A few doctors and others advocate clitoridotomy of adults, promoting it as a way of increasing sexual sensitivity and sexual pleasure. One claim is that a large clitoral hood may make stimulation of the clitoris difficult. Websites promoting the practice Circlist, bmezine and The Clitoral Hood Removal Information Page contain testimonials and two of them provide summaries of medical studies, including several finding that the majority of women reported improved sensation following the procedure (for example, 87.5% in Rathmann's 1959 study, and 75% in Knowles', as quoted in the summary of studies mentioned previously). However, this improved sensation does not last as the clitoris grows hard and less sensitive, much like when a male is circumcised.
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Clitoridectomy
Clitoridectomy means the partial or total removal of the external part of the clitoris. It was sometimes practiced in English-speaking nations well after the first half of the Twentieth Century, ostensibly to stop masturbation. [7]. Blue Cross Blue Shield paid for clitoridectomies in the U.S.A. until 1977 [8]. Clitoridectomy is still being practiced in isolated instances. It is, however, quite common in many countries of sub-Saharan Africa, east-Africa, Egypt, Sudan, and the Arabian Peninsula.
Type II circumcision is more extensive than type I, meaning clitoridectomy and sometimes also removal of the labia minora.
(There are reports that some women in certain "alternative lifestyles" communities in the United States have sought clitoridectomy because they are intrigued by the drama of the sacrifice involved with having their sensitive clitoris removed, while others seek the procedure in the hope that the pleasure in their buttocks and anal region will be greatly enhanced if the distraction of genital sensation is eliminated.)[citation needed]
Neurectomy, or severing of the pubic nerve to permanently numb the genitals and approximate the effect of a clitoridectomy was performed on institutionalized girls and women around the turn of the 20th Century in America and Australia, and electrical cauterization of the clitoris was reported to have been occasionally performed on mental patients in the USA to stop them from masturbating as recently as 1950.
The kind of things that sometimes happened to girls and women were documented in Alex Comfort's book, "The Anxiety Makers", Panther Edition, London, 1968:
About 1858, Dr Isaac Baker Brown, later president of the Medical Society of London, introduced the operation of clitoridectomy for the consequences of what he coyly calls 'peripheral excitement'. These, in his view, included epilepsy, hysteria and the convulsive disorders generally (page 109). In 1866 Brown published a series of 48 of such cases. This caused what Comfort called an 'almighty row'. Dr Baker Brown was ejected from the Obstetrical Society. Comfort says (page 111) that 'clitoridectomy fortunately disappeared from England'. However, it was taken up in the United States:
In 1894, we find Dr. Eyer of the St. John's Hospital, Ohio, dealing with nervousness and masturbation in a little girl by cauterizing the clitoris; this failing, a surgeon was called in to bury it with silver wire sutures - which the child tore and resumed the habit. The entire organ was then excised, with the crura. Six weeks after the operation the patient is reported as saying, 'You know there is nothing there now, so I could do nothing.' (Comfort, ibid, page 111)
Comfort says that this concern about masturbation 'did not really die out completely until the 1940s with the statistical studies of Kinsey' (Comfort, ibid, page 119)
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Infibulation
It has been suggested that this article or section be merged with Infibulation. (Discuss)
The form of female circumcision regarded as the most severe is Type III, which is also referred to as infibulation or pharaonic circumcision. This is often carried out by a "gedda," or matron of the village, without anaesthetic, on girls between the ages of two and six.
Infibulation replaces the vulva with a wall of flesh from the pubis to the anus, except for a pencil-size opening at the inferior portion of the vulva to allow urine and menstrual blood to pass through. A reverse infibulation is where the opening is left in the anterior part of the vulva in front of the uretha. After excision, the labia are sewn together, and since the skin is abraded and raw after being cut, the two surfaces will join via the natural healing and scar-formation process to form a smooth surface. The girl's legs are tied together for around two weeks to prevent her from moving the wound. [9]
The sewn-together labia majora are slightly opened before sexual intercourse by the girl's husband — girls will often be married at 12–16 years old — or by his female relatives, whose responsibility it is to inspect the wound every few weeks and open it some more if necessary.
During childbirth, the enlargement is too small to allow vaginal delivery, and so the infibulation must be opened completely and restored after delivery. Once again, the legs are tied together to allow the wound to heal, and the procedure is repeated for each subsequent act of intercourse or childbirth. When childbirth takes place in a hospital, the surgeons may preserve the infibulation by enlarging the vagina with deep episiotomies. Afterwards, the patient may insist that her vagina be closed again so that her husband does not reject her. [10]
This practice is reported to cause the disappearance of sexual pleasure for the women affected, as well as major medical complications, although advocates of the practice deny this, and continue to carry it out.
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Other types of female circumcision
Other forms are collectively referred to as Type IV. This includes a diverse range of practices, including pricking the clitoris with needles, burning or scarring the genitals as well as ripping or tearing of the vagina. Type IV is found primarily among isolated ethnic groups as well as in combination with other types.
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female genital mutilation (FGM).
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