Female Genital Mutilation and its Management

Definition and WHO Classification

FGM refers to "all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons." It has no health benefits, is a human rights violation and a form of child abuse. The WHO classification (1995, updated 2007) is examinable:

Type 1: Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
Type 2: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
Type 3: Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or labia majora, with or without excision of the clitoris (infibulation).
Type 4: All other harmful non-medical procedures, e.g. pricking, piercing, incising, scraping, cauterization. Type 4 may leave few or no visible signs once healed, so accurate contemporaneous documentation is essential.

Type 3 (infibulation) is practised almost exclusively in parts of Africa, with the highest prevalence in northeastern Africa (Somalia, Sudan, Ethiopia, Eritrea, Djibouti). An estimated 137,000 women and girls in England and Wales, born in FGM-practising countries, have undergone FGM, including 10,000 girls under 15.

UK Legal and Regulatory Duties

All health professionals must know the Female Genital Mutilation Act 2003 (England, Wales, Northern Ireland) and the Prohibition of FGM (Scotland) Act 2005. Both provide that:

FGM is illegal unless it is a surgical operation on a girl or woman, irrespective of age, that is necessary for her physical or mental health, or she is in any stage of labour or has just given birth and the procedure is for purposes connected with the labour/birth.
It is illegal to arrange, or assist in arranging, for a UK national or UK resident to be taken overseas for the purpose of FGM.
It is an offence for someone with parental responsibility to fail to protect a girl from the risk of FGM.
If FGM is confirmed in a girl under 18 (on examination, or because the patient/parent reports it has been done), reporting to the police is mandatory, within 1 month of confirmation [2015 mandatory reporting duty].

Other key points:

Female genital cosmetic surgery (FGCS) may itself be prohibited under the Acts unless necessary for the patient's physical or mental health; surgeons performing FGCS must ensure compliance.
Re-infibulation is illegal, has no clinical justification, and must not be performed under any circumstances (including after childbirth, where it is sometimes requested).
Health professionals must explain the UK law on FGM to affected women and must understand the distinction between recording (documenting FGM in the medical record for data collection) and reporting (referral to police and/or social services) — these carry different duties.
Clinicians must be familiar with the Health and Social Care Information Centre (HSCIC) FGM Enhanced Dataset requirement to submit identifiable data (anonymised only at the point of statistical analysis).
Mandatory police reporting applies specifically to confirmed FGM in under-18s; it is not mandatory to refer every pregnant woman with FGM to social services or police. Instead, an individual risk assessment (using a safeguarding risk-assessment tool) should be made by the clinical team; if the unborn child or any related child is considered at risk, a report must be made.

Service Organisation and Assessment

Every acute trust/health board should have a designated consultant and midwife responsible for FGM care, and mandatory FGM training (including de-infibulation technique) for obstetricians and midwives.
Specialist multidisciplinary FGM services, led by a consultant obstetrician/gynaecologist, should be self-referral accessible and offer information, safeguarding risk assessment, gynaecological assessment, and de-infibulation.
Interpreters must be professional, never family members; consultations must be private and non-judgemental.
Gynaecologists should proactively ask all women from FGM-practising communities whether they have undergone the procedure, as women may present with symptoms directly attributable to FGM or with coexisting morbidity. Examination should determine FGM type and whether de-infibulation is indicated, and identify complications such as epidermoid inclusion cysts.
All women with FGM should be offered psychological assessment/treatment, HIV/hepatitis B and C testing, and sexual health screening.

Complications

Short-term: haemorrhage (5–62%), urinary retention (8–53%), genital swelling (2–27%); infection, fever, and (rarely) death are reported. Long-term: UTI, dyspareunia and bacterial vaginosis (associated with FGM on systematic review), keloid/genital scarring, epidermoid inclusion cysts, clitoral neuroma, urinary obstruction/stasis with recurrent UTI and urinary/vaginal calculi (particularly type 2/3), and psychosexual dysfunction (anorgasmia reported in over 80% of women in some cohorts) and impaired sexual function across all types. No evidence links FGM directly to increased long-term prolapse or incontinence risk, though vaginal narrowing may hamper urodynamic investigation.

De-infibulation: Timing and Technique

Women likely to benefit (type 3 FGM with a sealed introitus) should ideally be counselled and offered de-infibulation before pregnancy, ideally before first sexual intercourse.
De-infibulation can be performed under local anaesthetic in an outpatient/clinic setting.
In pregnancy, de-infibulation may be performed antenatally, in the first stage of labour, or at the time of delivery, usually under local anaesthetic in a delivery suite room; it can also be performed perioperatively after caesarean section if planned de-infibulation was not carried out and birth proceeds by caesarean.
If the introitus is sufficiently open to permit vaginal examination and the urethral meatus is visible, de-infibulation is unlikely to be necessary.
If a woman requires intrapartum de-infibulation, the attending midwife/obstetrician must have completed de-infibulation training or be appropriately supervised.
A documented plan of care (agreed antenatally where possible) should record the intended timing and approach.
If planned antenatal/pre-labour de-infibulation is not carried out and the woman delivers by caesarean without de-infibulation, she should be followed up in a gynaecology/FGM clinic so de-infibulation can be offered before a subsequent pregnancy.
Re-infibulation must never be performed, including postpartum.
Labial tears in women with FGM are managed as in women without FGM, repaired where clinically indicated.
Clitoral reconstruction should not be performed — current evidence shows unacceptable complication rates without conclusive evidence of benefit.

Pregnancy Care

Consultant-led care is generally recommended for women with FGM given the higher likelihood of obstetric complications, though women with a previous uncomplicated vaginal delivery may be suitable for midwifery-led care.
All women, irrespective of country of origin, should be asked about FGM at the booking antenatal visit, with findings documented in the maternity record.
Women identified with FGM should be referred to the designated consultant obstetrician/midwife.
Hepatitis C screening should be offered in addition to routine antenatal screening (hepatitis B, HIV, syphilis).
All legal/regulatory documentation must be completed before discharge, checked by the discharging midwife.

High-Yield Exam Points

WHO Types 1–4: Type 1 = clitoridectomy; Type 2 = excision (clitoris + labia minora ± majora); Type 3 = infibulation (narrowing/sealing, ± clitoral excision); Type 4 = all other harmful procedures (may show no visible healed signs).
Mandatory police reporting applies only when FGM is confirmed in a girl under 18, and must occur within 1 month of confirmation — this is not the same duty as social services referral for pregnant women, which follows an individual risk assessment.
Re-infibulation is always illegal — a classic exam trap, including in the immediate postpartum setting.
De-infibulation timing options: before pregnancy (ideally before first intercourse), antenatally, first stage of labour, at delivery, or perioperatively post-caesarean — usually under local anaesthetic.
Clitoral reconstruction is not recommended by RCOG (unacceptable complication rate, no proven benefit) — distinguish this from de-infibulation, which is recommended where indicated.
Type 3 (infibulation) is geographically concentrated in the Horn of Africa (Somalia, Sudan, Ethiopia, Eritrea, Djibouti) with the highest national prevalence rates.

Source: RCOG Green-top Guideline No. 53 (2nd edition) (July 2015 (previously published 2009; preceded by an RCOG statement of the same title in 2003). RCOG announced in September 2023 that a partial update was in development but no revised/updated edition has been identified as published — treat this as the current, unretired text pending that update.)

Read the original on rcog.org.uk

Clinically reviewed by NHS obstetricians and gynaecologists · Source last updated July 2015 (previously published 2009; preceded by an RCOG statement of the same title in 2003). RCOG announced in September 2023 that a partial update was in development but no revised/updated edition has been identified as published — treat this as the current, unretired text pending that update.

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