Sexual Health, Pain

By Crista E. Johnson, MD, Jennifer R. Berman, MD, Rasha Ebeid, MD, Linda  H. Hewes, CNM, Kimmie L. Bui, MD, Fred E. Mecklenburg, MD, FACOG:  Female Genital Cutting (FGC), also known as Female Circumcision or Female Genital Mutilation, has existed for more than 2000 years.  It describes ritual surgical procedures performed on girls and young women as a ?rite of passage? to womanhood and marriage. FGC is practiced over than 28 African countries with prevalence rates from less than 5% to 100%. It is estimated that over 130 million females have been circumcised with 2 million more at risk annually for the procedure.

This operation can have serious physical, psychological and psychosexual complications. Following the procedure, hemorrhage, infection, septic shock and death can ensue, all of which are uncommon within this same population  in the U.S. Long-term complications include: dyspareunia, epidermal inclusion cysts, and recurrent urinary tract infections.

FGC has become a health and human rights issue worldwide with increasing numbers of immigrants and refugees from countries where this practice is indigenous. Here in the United States, health care professionals face the challenge of providing culturally-sensitive care to circumcised women who present with unique physical and emotional issues.  

The number of African immigrants residing in the United States is significant. In 2000, census data recorded 881,300 Africans, comprising almost 3% of the total foreign-born population, with 95% living in a metropolitan area.  In Washington DC, African-born immigrants comprise 11.21% of its foreign-born population,2 many of whom likely have undergone a form of FGC.

Understanding specific needs of circumcised women will enable providers to offer culturally-sensitive counseling, allowing informed decisions regarding their care.

In a recent study of 64 pregnant women with FGC,  51 (80%) declined study enrollment; 24 (47%) due to patient refusal, 10 (20%) spousal refusal, and 8 (16%) language barrier. Other obstacles encountered included: reluctance to disclose sensitive information, dearth of continuity of care, desire for female providers only, difficulty performing pelvic exams, and counseling. Of the 13 women enrolled, eight had normal spontaneous vaginal deliveries without excessive length of labor, blood loss or perineal lacerations. Four women delivered via cesarean for fetal indications, and one woman?s obstetrical care was lost to follow-up. None of the women desired future circumcision for their daughters.

The initial challenges of the study were language barriers and reluctance to disclose sensitive information. Many of the women recently immigrated, possessing limited English skills impeding their comprehension of their medical care. It became apparent that written translation of medical information and documents would have greatly facilitated patient comprehension of care rendered.

Continuity of care is crucial to foster a trusting rapport and facilitate dialogue between patient and provider.  Additionally, efforts to ensure a female provider during all aspects of care should be made.    Pelvic exams are made more difficult due to traumatic memories of the patient?s circumcision. Particularly, women with infibulation possess decreased vaginal introital size, making speculum or vaginal exams excruciatingly painful during clinical assessment for labor progression, fetal scalp electrode application, intrauterine pressure or bladder catheterization.  Counseling should ensue on antenatal defibulation (opening of the scar) during the second trimester.

Women with FGC have unique and specific needs of which providers must be aware of. It is imperative to establish a rapport with the patient and discuss issues complicated by circumcision by incorporating pre-conceptional counseling, psychological consultation, community-based educational programs and support networks. Armed with this information, circumcised women can make informed, educated decisions regarding their reproductive health, as well as well as their daughters.

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