BY MARGARET BRADY, RN, FNP-C, MSN

Assistant Professor

Hostos Community College

Grand Concourse

The Bronx, N.Y

As immigration from the Third World increases, more women who’ve undergone genital mutilation are entering Western health care facilities. Your next patient could be one at them. Would you know how to care for her?

IN 1980, WHEN I WAS WORKING AS A nurse in Saudi Arabia, I cared for many women who'd undergone female genital mutilation (FGM), also called female circumcision and infibulation. Today, as more people from countries that practice FGM travel to the United States and Canada, we're seeing more of these women in our own facilities. Yet most Western health care professionals know little about the procedure and the lifelong disabilities it can impose.

As nurses, we need to learn about FGM so we can care for our patients in a sensitive manner. In this article, I'll provide clinical information and cultural insights you can use to help a patient who's undergone FGM.

What It Is

Intended to eliminate sexual feelings in women, FGM involves the removal of genital tissue from girls. The average age for girls who undergo the procedure ranges from 4 to 7 years, but in some cultures, it's performed in infancy or during the teenage years. Although often associated with Islam, it's also practiced by people of other religions, including Christians, and has deep cultural significance. According to the World Health Organization, as many as 110 million women have undergone FGM. It's practiced in many African countries, some parts of the Middle East, and some parts of Malaysia and Indonesia.

Clinically, FGM can be categorized as follows:

Sunna involves the removal of the female prepuce. The least disfiguring, it's also the least commonly done.

Simple excision or clitoridectomy involves removal of the clitoris and parts of the labia minora.

Pharaonic circumcision or infibulation is the most mutilating. The clitoris, labia minora, and labia majora are removed. Then the raw surfaces are sutured and most of the vaginal orifice is closed. Only a small opening-often the size of the head of a matchstick-is left open for urination and menstruation.

In practice, these three categories often overlap, and women may have a combination of injuries.

Infibulation is the type of FGM most often performed in African countries-usually by untrained women working under primitive conditions and without anesthesia. The cutting instrument may be a razor blade, scissors, kitchen knife, or a piece of broken glass. Thorns, catgut, or horsehair may be used to hold the raw skin edges together.

The same unsterilized instruments may be used for many procedures, so bloodborne pathogens such as human immunodeficiency virus and hepatitis B virus are easily transmitted. Many girls die of hemorrhage or infection. Among survivors, long-term complications include recurrent urinary tract infections, infertility, and pelvic inflammatory disease.

Why does this practice persist? The reasons are a complicated mix of cultural and religious beliefs. In some cultures, people believe that an uncircumcised girl is unclean and unworthy of a husband. In fact, one of the major reasons for FGM is to diminish female sexuality and to ensure virginity and chastity before marriage and fidelity afterward.

Medical Complications

Depending on the extent of the mutilation, girls and women may develop long-term medical problems, which usually center on the genitourinary system. A woman who's been tightly infibulated must urinate drop by drop and may need 15 minutes to void. Because urination is painful, she may be reluctant to drink fluids. The result is frequent urinary tract infections.

Menstruation, which may last 10 days or longer, causes pain and often has a bad odor. Vaginal and uterine infections also are common.

Because the vaginal opening is so small, a pelvic examination causes severe pain even if you use a pediatric speculum or perform a simple bimanual examination. In some cases, a pelvic examination is impossible.

Pregnancy and Delivery

The complications involved in a vaginal delivery depend on the extent of the mutilation. Due to the excision of tissue and the formation of keloid scars and dermoid cysts, the perineal area lacks the elasticity to stretch during delivery. Many women need a deinfibulation (opening of the incisional area anteriorly). Otherwise, fetal descent may be obstructed, resulting in fetal hypoxia or death, and the mother may suffer bladder damage, fistulas, and perineal tears.

Because anatomic landmarks are obscured by scars and cysts, catheterizing the patient is difficult. Consider inserting an indwelling catheter early in labor so you won't lose valuable time if an emergency arises later.

During the postpartum period, carefully document fluid intake and output. Urine retention may lead to infection. The risk of postpartum hemorrhage is also increased because a full or rapidly filling bladder displaces the uterus upward and laterally, preventing the uterus from contracting. Existing scar tissue may delay perineal healing, and the combination of lochia and clots increases the risk of infection.

Psychosocial Considerations

When caring for a woman with FGM, remain culturally sensitive and nonjudgmental to gain her confidence and establish good rapport.

Your patient may view this procedure as a source of pride and acceptance by the community, enhancing her position in the household. She may not associate the many physical problems she has with the procedure. She may even wish to be reinfibulated after childbirth.

Educate your patient about the medical consequences of the procedure. This is especially important if she has daughters who may be at risk for FGM.

Because repeated episodes of pelvic inflammatory disease are common, your patient may be infertile. The psychological and social effects of infertility may be devastating; in most Muslim countries in which FGM is performed (for example, Saudi Arabia), a woman who can't have children can be divorced at will. She may also experience unresolved grief and low self-esteem. Because FGM is accepted in her culture, she may be unable to verbalize her feelings.

Global Pressure Against

FGM Some countries have already banned FGM. Sweden outlawed FGM in 1982, and the United Kingdom passed a similar law in 1985. France, Switzerland, Kenya, and Senegal also have banned the practice. In Canada, the procedure is outlawed as a human rights violation.

On September 30, 1996, the U.S. Congress passed legislation making practicing FGM on girls under 18 a federal criminal offense. Many states, including California, Wisconsin, and North Dakota, have enacted state laws making the procedure illegal. In New York, participating in FGM on a minor is a felony, punishable by 1 year in jail.

In a significant ruling last December, Egypt's highest court upheld a ban on FGM that was imposed the previous year. Rejecting the argument by Islamic conservatives that FGM is a religious issue, the court ruled that the practice isn't mandated by the Koran. The ruling suggests that attitudes toward FGM are changing.

As nurses, how can we support these changes? By acting as advocates for women and girls affected by FGM and increasing professional and public awareness about the practice. We must report it when it involves a girl under 18, because it's now legally considered child abuse. We should also lobby to extend protection to women of all ages. Although the practice can still be legally performed on adults in some states, the ethical concerns of participating in such a procedure are complex. I believe that nurses should refuse to participate in any way because doing so condones the practice and perpetuates a medically unnecessary and potentially dangerous practice.

We also need to educate people from societies that practice FGM. To maximize the potential for change, knowledgeable people who understand the cultural traditions that drive these practices should sensitively explain the dangers of this procedure and the lifelong disabilities it causes.

By speaking up, we can give women a choice and help eliminate this unsafe practice. I

SELECTED REFERENCES

Council Report: "Female Genital Mutilation," JAMA. 274(21):1714-1716, December 6, 1995.

Shorten, A.: "Female Circumcision: Understand Special Needs," Holistic Nursing Practice. 9(2):6673, January 1995.

Toubia, N.: "Female Circumcision as a Public Health Issue:' The New England Journal of Medicine. 331(11):712-716, September 15, 1994.

SELECTED WEB SITE

Women's International Network News: http://nocirc.org/symposia/first/hosken.html

http//www.springnet.com NURSING98, September page 50-51