Page 16 - JSOM Winter 2017

Female Genital Mutilation as a Concern for Special Operations
and Tactical Emergency Medical Support Medics

Arthur C. Wittich, DO

ABSTRACT
Female genital mutilation (FGM), frequently called female termed female genital cutting and female circumcision, FGM is
genital cutting or female circumcision, is the intentional dis- a painful, destructive, culturally mandated surgical disfigure-
figurement of the external genitalia in young girls and women ment of the genitalia of young girls and women.
for the purpose of reducing libido and ensuring premarital
virginity. This traditional, nontherapeutic procedure to sup- The origin of FGM is unknown; however, historians and ar-
press libido and prevent sexual intercourse before marriage cheologists cite evidence of FGM in Egyptian mummies from
has been pervasive in Northern Africa, the Middle East, and the time of the pharaohs in the 5th century bc. FGM predates
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the Arabian peninsula for over 2,500 years. FGM permanently Christianity and Islam. Although Christians and nonreligious
destroys the genital anatomy while frequently causing multiple primitive cultures practiced FGM worldwide, it continues to
and serious complications. The International Federation of be prevalent in Islam-dominant regions of the world where
Gynecology and Obstetrics proposed a classification system the practice began. 3–7 FGM was pervasive in the Levant, the
of FGM according to the specific genital anatomy removed Fertile Crescent, and the Arabian peninsula; with Islamic ad-
and the extensiveness of genital disfigurement. Although it has vancement in the 13th century, FGM also became prevalent in
been ruled illegal in most countries, FGM continues to be per- Indonesia, Malaysia, and Asia. 2–7
formed worldwide. With African, Asian, and Middle Eastern
immigration to the United States and Europe, western coun- FGM has been declared illegal in most countries, including 24
tries are experiencing FGM in regions where these immigrants African nations, over the past three decades, yet more than
have concentrated. As deployments of Special Operations 200 million girls and women alive today were subjected to
Forces (SOF) increase to regions in which FGM is pervasive, FGM and more than 3 million girls are at high risk annually. 5–7
and as African, Asian, and Middle Eastern immigration to the
United States increases, SOF and Tactical Emergency Medi- Using a sharp knife or razor blade, without anesthesia or ster-
cal Support (TEMS) medics will necessarily be called upon ile conditions, traditional midwives perform genital mutila-
to evaluate and treat complications resulting from FGM. The tion by brutally excising the clitoris, prepuce, and a portion
purpose of this article is to educate SOF/TEMS medical per- or all of the labia minora and majora. This disfigurement has
sonnel about the history, geographic regions, classification of been classified by the International Federation of Gynecology
procedures, complications, and medical treatment of patients and Obstetrics (FIGO) and the World Health Organization
with FGM. (WHO) into four types of FGM 7,10 according to the anatomic
tissue excised and disfigurement of the external genitalia. The
Keywords: female genital mutilation; FGM; female circumci- female genitalia have adjacent vessels and urinary tract struc-
sion; external genitalia; International Federation of Gyne- tures that are prone to injury during the mutilation procedure.
cology and Obstetrics Not surprisingly, serious injury is not uncommon and includes
hemorrhage, shock, urinary fistula, and incontinence. Late
complications such as psychological disorders, chronic depres-
sion, infertility, obstetric complications, chronic urinary tract
Introduction
infection, and incontinence are usually lifelong problems.
This article is an adaptation of an article originally published
by the author in Military Medicine 20 years ago. Since that This destructive procedure has been condemned and outlawed
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publication, the subject of female genital mutilation (FGM) by multiple international organizations, yet it continues today.
progressed from a little-known entity in the medical literature Prevention of FGM is not in the purview of medics, but med-
to a frequently discussed world health concern. 2,3 Sometimes ics must be knowledgeable of the procedure and the known

Address correspondence to drwittich@aol.com or 6725 Catskill Road, Lorton, VA 22079
COL (Ret) Wittich has 50 years of uniformed service as an enlisted Navy Corpsman and Army Medical Corp Officer with assignments in op-
erational and clinical medicine as intern, resident, staff physician, service chief, department chief, brigade surgeon, division surgeon, hospital
commander, and professor at Uniformed Services University of the Health Sciences. After 44 years in the Army, Dr Wittich retired from Fort
Belvoir Community Hospital. Among numerous professional organizations, he is a member of the Society of Gynecologic Surgeons, the Excelsior
Surgical Society, and the Special Operations Medical Association. He holds fellowships in the American College of Surgeons, the International
College of Surgeons, and the American College of Osteopathic Obstetrics and Gynecology.

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