Page 17 - JSOM Winter 2017

complications, and how to manage the complications that are opening to permit intercourse and vaginal obstetric delivery.
treatable outside the hospital setting. Attempting intercourse without surgically opening the vagina
via a procedure known as deinfibulation would be traumatic.
This procedure to release the healed bilateral portions of labia
Types of FGM
majora sewn together during infibulation (Figure 2) requires
FIGO classified FGM into three distinct types in 1994 7–10 ac- surgically opening the scar tissue in the midline under local
cording to the anatomic tissue removed from the genitalia and anesthesia (Figure 3). Deinfibulation is incorrectly termed “re-
the genital disfigurement 7-10 (Figure 1). In 2007, a fourth type versal of FGM”; the removal of genital tissue during FGM
was added to this classification. WHO adopted these criteria cannot be reversed. Deinfibulation should be performed be-
10
for describing FGM: fore pregnancy, but it can be performed during labor. 7,9
• Type I: termed the “circumcision proper” and the Discussion
“sunna type,” and includes excision of the clitoris and
prepuce The misguided procedures aimed at suppressing libido and pre-
• Type II: termed the “excision type” and includes re- venting sexual intercourse by removing portions of all of the
moval of the clitoris, prepuce, and total excision of the external genitalia in young girls and women began in North
labia minora Africa during the pre-Christian and pre-Islamic eras. This bru-
• Type III: known as the “infibulation type,” this includes tal disfigurement of girls and women is condemned by all in-
excision of the clitoris, prepuce, labia minora, and la- ternational health organizations and by 42 nations, yet more
bia majora, then stitching the remaining perineal tissue than 200 million girls and women have undergone FGM and
together, leaving a narrow opening as the distal vagina. 3 million are at risk annually. 7–9 During the past year, in Michi-
Type III is also referred to as the “pharaonic method,” gan and California, several immigrant physicians have been
referring to the era of the Egyptian pharaohs. incarcerated by state courts of law for performing FGM. 11–13
• Type IV: includes picking, piercing, stretching, cauteriz- Recently, a national television news program reported up to
ing, or incising the clitoris and surrounding tissue. This 500,000 young girls in the United States are at risk for FGM 14
method includes all other harmful procedures to the even though it is illegal in most states and FGM providers have
genitalia not described in types I–III to prevent sexual been imprisoned. 11–14
intercourse.
Complications immediately following FGM include severe
pain, neurogenic and hemorrhagic shock, fever, excessive
As demonstrated in Figure 1, type I and type II will permit
intercourse at time of marriage or when desired. Intercourse blood loss, infection, tetanus, injury to the vagina and urinary
may require blunt or sharp dilation of the vagina, which may structures, nonhealing wounds, and, occasionally, death. Late
be painful, traumatic, or difficult, but usually possible. The
infibulation (type III) requires surgery to open the vaginal Figure 2 Infibulation (Type III FGM).

Figure 1 WHO/FIGO classification for female genital mutilation.

After removing labia minora and majora, remaining perineum is sewn
closed except for small vaginal opening.
Figure 3 Deinfibulation surgical procedure for emergency
obstetrical delivery.

(A) Normal female genitalia. (B) Type I FGM, known as the “circum- (A) Local anesthesia injection (B) Deinfibulation using scissors
cision proper” and “sunna method.” (C) Type II FGM, known as the into infibulation scar before after injection of local anesthesia
“excision type.” (D) Type III FGM, termed “infibulation method” and deinfibulation. to open the vagina to permit
“pharaonic type.” vaginal delivery in an emergency.

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