Page 18 - JSOM Winter 2017

FGM complications usually are permanent and life altering. Not surprisingly, the serious complication resulting from FGM
These include dysuria, recurrent cystitis and vaginitis, urinary of any of the four types is mortality. Frontline SOF/TEMS med-
incontinence, fistula, hematometra and hematocolpos, colpo- ics should use their skills and resources to relieve pain, assist
clesis, keloid formation, vaginal calculi, dermoid cysts, bar- these distressed patients, perform necessary procedures, and
tholinitis, urinary retention, dyspareunia, infertility, obstetric make all effort to preserve a life. All must accept that many
complications, psychological complications, chronic depres- serious FGM complications are beyond the medic’s capability.
sion, and intractable pain. 7,9,10 Even under ideal circumstances As in all patient-care situations, evaluate, treat according to
with experienced surgeons and clinicians available, correcting available skills and resources, and do no harm.
anatomic and urinary tract complications is rarely possible.
These girls and women are often rejected by family and com- Conclusion
munity, and relegated to a life of misery and shame.
With FGM being common in many areas of operation for
How should a Special Operations Forces (SOF) or tacti- SOF, particularly Africa, the Middle East, and Asia, and with
cal emergency medical support (TEMS) medic react when increasing US immigration from the FGM-prevalent regions,
responding to a FGM injury or complication? As with any SOF/TEMS medics will necessarily become involved with
medical emergency, evaluate the patient, assess the presenting medical evaluation of FGM complications. After evaluation,
complaint, then treat the patient accordingly with available provider expertise and medical resources will necessarily dic-
resources. Aside from the medical care rendered, cultural and tate patient treatment. Immediate complications, including
religious traditions must be addressed and respected. Male pain, bleeding, local infection, acute urinary tract infection,
nonfamily members culturally do not touch adult females, es- nonhealing wounds, and urinary retention, can be treated with
pecially in the private areas. A female medic is preferable when analgesics, antibiotics, cleansing, clean dressings, and bladder
possible, but if not, all effort should be made to convince the catheterization. Serious immediate complications such as hem-
patient and her family that medical care is necessary. It may be orrhagic shock or sepsis will necessarily indicate Tactical Com-
necessary to instruct a female family member what needs to bat Casualty Care and standard trauma management, pending
be performed and show her how to do it. resources. Late complications, including urinary fistula, incon-
tinence, depression, dyspareunia, and obstetric emergencies,
In many FGM-prevalent regions, this barbaric ritual is a cul- require specialized care usually not available in austere areas
tural rite of passage and considered a celebratory event. If a of deployment. Surgical, urologic, obstetric, and psychiatric
SOF/TEMS medic is requested to perform or assist in per- consultations are usually necessary but rarely available.
forming this procedure, which is unlikely but possible, strong
resistance is mandatory. It is recommended that an emphatic Domestic urban regions with high concentrations of African,
response should state that this procedure is considered unethi- Middle Eastern, and Asian immigrants usually have local spe-
cal and would violate the medic’s medical care code of conduct. cialists familiar with FGM. Unfortunately, many FGM patients
and FGM performers are controlled by tradition and cultural
When an FGM patient needing medical attention is evaluated myths rather than by physiology and medical knowledge. Pa-
and permission to treat has been established, acute bleeding tients’ families continue to have their daughters mutilated and
must be controlled with direct pressure, ligatures, sutures, and immigrant doctors continue to mutilate these young girls. Un-
cold compresses. Local infection requires antibiotic therapy; believably, though FGM is illegal and condemned throughout
cleansing; debridement, if indicated; and clean dressings. If the world, and with the known serious complications that fre-
urinary retention is present, catheterization and an indwell- quently cause life-altering suffering and, occasionally, death,
ing catheter are indicated, particularly when there is edema FGM persists. Arrest and incarceration of FGM providers
and swelling. Wound breakdown and disruption should be have not been a deterrent in the United States, where, report-
cleaned, dressed, and left open for healing by delayed pri- edly, an increasing number of young girls are mutilated or at
mary closure. Clean sitz baths, if available, are recommended risk. 14
several times a day. Urinary incontinence and urinary fistula
require urologic or surgical consultation, but instruction on All SOF/TEMS medics, particularly those deployed in FGM-
basic hygiene is indicated and indwelling urinary catheteriza- prevalent areas and those working in domestic regions with a
tion may be of temporary relief. high African or Asian immigrant population, need to be aware
of FGM procedures and the early and late complications.
Severe hemorrhage requires transfusion, when available. Se- Evaluation and treatment of these patients will often be chal-
vere infection requires broad-spectrum antibiotics, either in- lenging, unrewarding, and beyond the medics’ administrative
travenous or oral, and possible debridement of necrotic tissue. and medical care capabilities.
Psychological decomposition and severe depression require
psychiatric therapy not within the medic’s practice. Acknowledgments
The author thanks Cheryl Armstrong, LPN, for her technical
Obstetric emergencies usually require deinfibulation, as shown and administrative assistance in writing this article.
in Figure 3. Inject 5–10mL of local anesthesia superficially into
the FGM area and place one or two fingers into the vaginal Disclosure
opening toward the pubic bone. Then, with scissors, cut the The author has nothing to disclose.
previous scar, as shown in Figure 3B. If the vagina cannot be
opened, a cesarean section is necessary. Either way, the risk for References
perinatal morbidity is high. Deinfibulation can be performed 1. Wittich A, Salminen E. Genital mutilation of young girls tradition-
in an emergency situation by medics who understand the pro- ally practiced in military significant regions of the world. Mil Med.
cedure and the genital anatomy. 1997;162(10):677–679.

16 | JSOM Volume 17, Edition 4/Winter 2017