Case Scenario

One evening when I was on call, a 22-year-old woman from Somalia arrived in labor. She had received no prenatal care, and her English was limited, so her husband spoke for her. I had never seen a patient with a female circumcision before, but now, on doing her initial examination, I noticed a narrow introitus with extensive scarring.

She gave birth to a healthy girl in a delivery that was uneventful except for extensive tearing. The woman's anatomy was distorted. I didn't know whether to reapproximate the scars in an attempt to restore her predelivery anatomy or to reconstruct a more physiologic introitus out of the scar and torn tissue. Communication with the patient was difficult. Although the husband seemed very caring and concerned about his wife, the nurse who was working with me suggested that the women might be ostracized if the repair was not performed to cultural standards. I ended up trying to approximate the edges as best I could, erring on the side of leaving the introitus open. The woman followed up in the clinic after I was off the service, and I never saw her again.

I'm still disturbed by the case and haven't come to a firm conclusion about how I should have handled it. What did the circumcision mean to this woman? What cultural taboos would she have endured if I did not meet her expectations? Would she still be safe and accepted in her family and community? What would be the best thing for her medically? Was I willing to sew up the introitus even if that was the patient's desire? What resources did I have to sort out these issues at a suburban hospital in the middle of the night?

Commentary

Girls in Somalia are circumcised before the age of five years, usually by female family members, although it is also performed legally there in some hospitals. Uncircumcised women are seen as unclean. The most common procedure is “fibulation,” which involves removing and suturing most external genital tissue, leaving only a posterior opening. In 1995, it was estimated that 98 percent of Somali women had undergone female genital mutilation.¹

Although most Somalis are Sunni Moslems, female genital mutilation does not have a religious tradition. Female genital mutilation is primarily a prepubertal custom—a rite of passage, a physical marking of marriageability, the insurance of virginity, and the formation of a chastity belt of a woman's own tissue. The rite symbolizes total social control of a woman's sexual pleasure and comprises a spectrum of surgical excisions.² This procedure may range from removal of the clitoral prepuce to complete removal of the clitoris and parts of the labia minora, and occasionally the majora, with suture of the remaining tissue to occlude the external genitalia. In many countries, reinfibulation is commonly performed following delivery, reestablishing the small opening.

The health complications of female genital mutilation are both immediate and delayed and are referred to as the “three feminine sorrows”: the sorrows on the day of mutilation or circumcision, the wedding night when the opening must be cut and the birth of the baby when the opening must be enlarged.^3,4

Pain is the major accompaniment at each point. Hemorrhage, shock, infection, septicemia and death can occur at the time of the procedure.² Chronic infections, fistula, incontinence, urethral stenosis, delayed hematocolpos, menstrual disorders, vaginal stenosis, infertility or even sterility are other complications.²

Despite the social pressures to continue the tradition, many women who have undergone female genital mutilation believe the most important of her sorrows is the loss of trust—a sense of betrayal by her own mother.

In this case, we are presented with an interesting situation in which a young Somali woman is linguistically challenged, clinging to tradition and dependent on another person's communication. She is a stranger to our customs and may not fully understand either her tradition or the health consequences.⁵

If the patient in this case is truly requesting to be reinfibulated, having a reapproximation of the scarred edges of the labia majora, then we must say “no” for both medical and legal reasons. Some physicians are thought to perform extended episiotomies or cesarean deliveries to avoid this issue altogether, but most physicians would not reapproximate the tissue or even place an extra unwanted stitch after delivery.

Current U.S. law prohibits performing female genital mutilation, and the practice has been criminalized in at least 10 states.⁶ The Federal Prohibition of Female Genital Mutilation Act of 1995 prohibits and criminalizes genital mutilation procedures on females under the age of 18 years, unless the procedure is deemed medically necessary and performed by a medical practitioner. However, medical indications to justify such a procedure are virtually nonexistent. Another exception allows the procedure if the recipient is in labor or has just given birth and the procedure was performed for medical purposes connected with labor or birth by a licensed medical practitioner.

With regard to this patient, a more important question than that of the repair is how the delivery itself was handled. By appropriate care, including anesthesia and a mid-longitudinal cut, extensive tearing might have been avoided.^7,8 Or, as is done often in England and Denmark, the woman could have been prepared with deinfibulation in her second trimester. It would have been helpful to have an obstetrician or family physician available who was familiar with the social and medical ramifications of female genital mutilation. Somali women in particular have indicated that clinician familiarity with the practice and the availability of women clinicians were among their greatest health priorities.⁸

Finally, the physician should have addressed a future issue—how to prevent the circumcision of the patient's new daughter. California law obligates the state to intercede on behalf of the child with community education (Cal Penal Code §273.4).^6,9

The offices of women's health within each state may be the best resource for culturally appropriate information and education for both the health care professional and the community.