Complications of Female Genital Mutilation/Cutting | Article

This chapter should be cited as follows:
Koigi PK, Kihara AB, Glob. libr. women's med.,
ISSN: 1756-2228; DOI 10.3843/GLOWM.417813

The Continuous Textbook of Women’s Medicine Series – Gynecology Module

Volume 1

Female genital mutilation

Volume Editor: Professor Anne-Beatrice Kihara, University of Nairobi, Kenya,
President-elect. The International Federation of Gynecology and Obestetrics FIGO
President, African Federation of Obstetricians and Gynecologists (AFOG)

Chapter

Complications of Female Genital Mutilation/Cutting

First published: July 2022

AUTHORS

Paul Kamau Koigi, MBChB (UON); PGD-SRM (UK); MMed Obstetrics and Gynaecology (UON); MCOG (ECSA); PhD (UON - Ongoing)

Consultant Obstetrician & Gynaecologist and Acting Head of Research, The Nairobi Hospital; Communications for Development (C4D) advocacy expert and trainer; Deputy Editor-in-Chief, Journal of Obstetrics and Gynaecology of East and Central Africa (JOGECA); Member & Chairman of the Scientific Committee, Kenya Obstetrical and Gynaecological Society (KOGS); Continuous Professional Development Coordinator & Assistant Secretary General, Fertility and Andrology Society of Kenya (FASK), Kenya

Anne Beatrice Kihara, MBChB (UON); MMed Obstetrics and Gynaecology (UON); FCOG (ECSA)

Senior Lecturer, Department of Obstetrics and Gynaecology, University of Nairobi; Former President, Kenya Obstetrical and Gynaecological Society (KOGS), Kenya; President, African Federation of Obstetrics and Gynaecology (AFOG); President-Elect, International Federation of Gynaecology and Obstetrics (FIGO)

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INTRODUCTION

"Female genital mutilation/cutting (FGM/C)" refers to all procedures that involve partial or total non-medical excision or injury of the female external genitalia. It has no health benefits, is typically culturally driven, and is associated with a kaleidoscope of adverse health consequences. In addition to these consequences, FGM/C directly violates multiple human rights.¹

Typically, the adverse effects of FGM/C increase in direct proportion with the extent of the procedure.² The complications of FGM/C are typically considered from two main perspectives:

According to the timing of their occurrence: immediate and delayed.²^,³
According to the dimensional function affected: obstetric; sexual; psychological; social; and socioeconomic.¹

IMMEDIATE COMPLICATIONS OF FGM/C

The immediate complications associated with FGM/C include the following: pain;⁴ genital swelling; bleeding; local abscess formation; rectal injury;¹ genital ulceration;⁵ shock (hemorrhagic, neurogenic and/or septic);¹^,³ acute urinary retention with dysuria;⁶ dislocations and fractures (from being restrained);³ and death.⁷

DELAYED PHYSICAL COMPLICATIONS OF FGM/C

The delayed complications of FGM/C are those that develop after a time lag. They are shown in Table 1.

Delayed physical complications of FGM/C.

System affected	Delayed complication
General	Increased incidence of human immunodeficiency virus (HIV), Chlamydia trachomatis, Clostridium tetani, Neisseria gonorrhoea, Treponema pallidum, Candida albicans, Trichomonas vaginalis, Pseudomonas pyocyanea, Staphylococcus aureus, herpes simplex virus (HSV) type 2, hepatitis B and hepatitis C infections¹^,⁵^,⁸
Reproductive tract	Chronic and recurrent genital tract infections, including bacterial vaginosis⁹
	Chronic pelvic pain⁴
	Menstrual problems: dysmenorrhea, hematocolpos³
	Vulvodynia and/or clitorodynia¹
	Keloid and synechia formation due to poor healing¹⁰
	Para-clitoral cyst¹¹ and atheroma formation,¹² clitoral neuroma formation and formation of clitoral stones¹³^,¹⁴^,¹⁵
Urinary tract	Renal failure⁶
	Urinary incontinence due to urethral damage⁶
	Lower urinary tract symptoms: nocturia, intermittency, incomplete voiding,⁶^,¹⁶^,¹⁷ and dysuria⁴
Gastrointestinal	Fecal incontinence due to rectal sphincter injury¹⁸

OBSTETRIC COMPLICATIONS OF FGM/C

The experience of FGM/C makes the navigation of the journey of pregnancy objectively more precarious, both during and after the pregnancy, for both the mother and the fetus. These complications are shown in Table 2, with an emphasis on the victim and timing of the complications.

Obstetric complications of FGM/C.

Victim of complication	Timing of complication	Complication
Maternal¹⁹^,²⁰^,²¹^,²²^,²³	Early pregnancy	Higher risk of miscarriage²⁴
	Throughout pregnancy	Delayed initiation of antenatal care seeking and lower overall frequency of clinic attendance²⁵
		Recurrent urinary tract infections during pregnancy²⁴
		Higher risk of preterm labor and delivery²⁶
	Intrapartum	Lower skilled birth attendance²⁷
		Difficulty in performing vaginal examinations,² hence delaying diagnosis and treatment²⁶
		Possible need for defibulation to facilitate delivery²⁸^,²⁹
		Need for instrumental and operative delivery (cesarean section)³⁰
		Labor dystocia⁴
		Uterine rupture³⁰
		Need for episiotomy⁴^,³¹
		Primary post-partum hemorrhage³¹
		Obstetric lacerations,⁴^,³² including anal sphincter injury³³^,³⁴
		Longer duration of hospital admission
		Independent association with eclampsia³⁵
	Puerperium and beyond	Puerperal sepsis
		Pelvic floor damage³⁶
		Obstetric fistula formation (RVF and VVF)³⁷
Neonatal¹⁰^,¹⁹^,³⁸^,³⁹	N/A	Low Apgar scores³²
		Low birth weight
		Stillbirth or early neonatal death⁴⁰
		Hypoxic ischemic encephalopathy
		Need for neonatal resuscitation

N/A, not applicable; RVF, rectovaginal fistula; VVF, vesicovaginal fistula.

SEXUAL COMPLICATIONS OF FGM/C

There are multiple sexual complications associated with female genital mutilation/cutting. These complications are more often experienced by those who have undergone type III FGM/C. They include the following: failed marital consummation;⁴¹ reduced sexual desire and arousal;⁴² reduce orgasmic frequency;⁴³ development of superficial and/or deep dyspareunia;⁴ decreased sexual satisfaction; reduced lubrication during sexual intercourse; and infertility (due to recurrent and chronic genital infections).²^,³^,⁴⁴^,⁴⁵ Perhaps an even more frustrating aspect of the sexual complications of FGM/C is that defibulation may result in worsening of sexual experience in up to 1/5 of its subscribers.⁴⁶

PSYCHOLOGICAL COMPLICATIONS OF FGM/C

Over and above the physical trauma incurred from the infliction of damage by this untoward procedure, FGM/C is associated with multiple psychological complications, viz., post-traumatic stress disorder (PTSD); impaired memory function; anxiety disorders; depression; neuroses; psychosis; psychosomatic diseases;¹^,²^,³^,⁴⁷^,⁴⁸ and distorted body image.²⁷ In congruence with the physical complications, the psychological complications increase in severity with the extent of the FGM/C.⁴⁹

Amongst men with partners who have undergone FGM/C, there have been reports of difficulty in vaginal penetration, infliction of penile wounds, development of penile infections, and the development of psychosexual problems, including reduced sexual satisfaction.⁴⁰

Given the fact that the cultural contexts that perpetuate this practice are also typically characterized by low mental health-seeking behavior,⁵⁰ addressing the psychological wounds and scars that these women bear remains an uphill task.

SOCIAL COMPLICATIONS OF FGM/C

The social complications of FGM/C may span to include those that directly afflict the woman, those that afflict her immediate family; and those that afflict the society at large. These complications are shown in Table 3.

Social complications of FGM/C.

Party afflicted	Complication
The woman	Irritability and persistent hostility⁴⁸
	Reduction in quality of life³
	Reduction in length of life⁵
The couple	Marital conflict due to dyspareunia⁵¹
	Increased risk of intimate partner violence (physical, sexual, and emotional)⁵²
	Reduced quality of communication within the couple⁴⁰
The children of the woman	Increased risk of FGM/C being performed on her children⁵¹^,⁵³^,⁵⁴^,⁵⁵
The woman and other women in the society	Perpetuation of female gender oppression⁵¹^,⁵⁶ due to conformation to subjective cultural norms⁵³ intending to reduce female sexuality⁵⁷
The woman and other women in the society	Poor health-seeking behavior due to cultural deference rules that silence raising these concerns during consultations⁵⁸

FGM/C, female genital mutilation/cutting.

SOCIOECONOMIC COMPLICATIONS OF FGM/C

There are three main recognized socioeconomic consequences of FGM/C:⁵

Increased economic burden on the individual, society, and health system.
Increased social burden of disability on women and on the community.
Reduced ability of women to participate in economic and social activities.

A NEW INTEGRATIVE APPROACH TOWARDS FGM/C COMPLICATIONS

In order to effectively address the subject of FGM from a public health angle, it may be possible to introduce a third integrative perspective, which will enhance the capacity to contextualize and thus address the complications.

Considering FGM/C complications according to the sequence of development of the complications in relation to the procedure, with consideration of the parties afflicted. This would result in the categorization of the complications into the following:

Primary: direct complications associated with the procedure (Immediate) that afflict the patient.
Secondary: complications that follow the procedure but may be delayed and may afflict other systems other than the reproductive system. These include obstetric complications that affect the neonate.
Tertiary: complications that afflict the immediate family members of the women that undergo FGM/C.
Quaternary: complications that afflict the society at large as a long-term consequence of the suffering of the women and their families. This includes the professional aspect that seeks to medicalize FGM/C.

PRACTICE RECOMMENDATIONS

Female genital mutilation/cutting has no health benefits.
Complications of female genital mutilation/cutting may be as follows: immediate; delayed physical; obstetric; sexual; psychological; social; and socioeconomic.
Infibulation complicates obstetric examination.
Defibulation and episiotomy may be required to facilitate delivery due to vaginal and perineal fibrosis.
Offer clinical and mental health attention to those who have undergone female genital mutilation/cutting, as the cultural context is also associated with reduced health-seeking behavior.
Multidisciplinary management is vital in ensuring that the kaleidoscope of complications resulting from female genital mutilation/cutting are conclusively addressed.

CONFLICTS OF INTEREST

The author(s) of this chapter declare that they have no interests that conflict with the contents of the chapter.

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