The sequelae of female circumcision

Female circumcision, which includes all deliberate mutilations of a girl's genitalia, is still done in many parts of the world, sometimes as early as 8 days after birth, but usually at puberty, when it is part of a coming of age ritual which is willingly entered into, and endured with stoicism. In some districts all your female patients will be circumcised. The commoner types are:

Circumcision proper (Sunna circumcision) removes only the clitoral prepuce, and is analogous to male circumcision.

Excision removes the prepuce, the glans, and sometimes the clitoris itself, together with part or all of the labia minora.

Infibulation (Pharaonic circumcision) is still almost universal among Muslims of the Sudan. It excises a varying amount of vulval tissue, and partly closes the vaginal orifice. In its most drastic form all or part of the mons veneris, the labia majora and minora, and the clitoris are removed, and the raw areas are left to heal across the lower vagina. A piece of wood (commonly a matchstick) is then inserted, and the girl's legs are strapped together for 40 days while the lesion heals. The final result is a flattened vulva, without labia, made of a membrane of skin which hides her urinary meatus, and is marked by a midline scar extending backwards from her symphysis pubis to her narrowed and scarred vulval orifice, which may only admit one finger, and sometimes not even that.

ZEINAB (6 years) was laid naked across a bed, securely tied by her arms and ankles. With a deep sweep of the razor, the midwife removed the anterior two-thirds of one of her labia, together with her clitoris. The unfortunate girl's shrieks were drowned by ''That's nothing to fuss about!''[md]while the midwife removed her other labium in the same way. As usual, there was a sadistic smile on the face of the operator, and the whole business was thoroughly enjoyed by the priviledged spectators. Haemorrhage is always profuse, and was dealt with as usual. A clamp, made of a bent piece of split cane, was adjusted so as to grip the raw edges together, and its ends tied. For the next three weeks the girl's life was far from being a bed of roses, the clamp remained in place, and her urine had to find its way out as best it could[...] Derived from Alan Worsley's account of infibulation and female circumcision in the Sudan. Verzin JA, ''Sequelae of Female Circumcision'. Tropical Doctor 1975;163[nd]69.[-3] Worsley A, ''Circumcision in the Sudan'. Journal of Obstetrics and Gynaecology of the British Empire. 1938;45:686. Fig. Fig. 20-22 FEMALE CIRCUMCISION. A, the usual appearance of the end result of circumcision. B, a midline circumcision scar healing in patches to give a perforated appearance. C, in its extreme form the narrowed introitus will only admit the point of a fine probe. D, a large implantation dermoid following circumcision. After JA Verzin, with the kind permission of the editor of Tropical Doctor.

THE SEQUELAE OF CIRCUMCISION COMPLICATIONS. can occur at various times in the patient's life. Their true incidence is not known.

Immediate complications: (1) Haemorrhage (common). (2) Infection. (3) Retention of urine. (4) Trauma to her rectum and anus. (5) Amputation of the urethra, resulting in a vesicovaginal fistula.

Late complications: (1) Implantation dermoids (common) which may be as large as a football, and hang down over her introitus. (2) Coital difficulties due to excessive stenosis. In its extreme form the narrowed introitus will barely admit a fine probe, and may lead to anal intercourse. (3) Infertility; pregnancy can however occur when the introitus is too tight to admit the penis. (4) Keloid formation. (5) Urinary tract infection. (6) Difficulty of micturition may occur after many years. (7) Calculus formation in her vagina. (8) Haematocolpos.

Obstetric complications: (1) The impossibility of making an adequate vaginal examination. (2) Difficulty passing a catheter. (4) Delay in labour due to a tight perineum.

DECIRCUMCISION FOR DYSPAREUNIA. Under local anaesthesia, saddle block (A 7.7), subarachnoid anaesthesia (A 8.1), or ketamine, make a midline incision forwards from her stenosed vulval orifice.

EXCISION OF A DERMOID CYST. Make an elliptical incision round the base of the mass and excise it.

DIFFICULTY IN LABOUR. If pharaonic circumcision is practised the introitus will not be big enough to allow the baby to pass, so it will be the local practice to make an anterior episiotomy (''the cut'). Failure to make one delays or obstructs labour, and may force the baby's head backwards and cause severe perineal lacerations. The anterior episiotomy is usually adequate; but if it is not, make a posterolateral one also.

CAUTION ! Bladder and urethral fistulae have followed carelessly done anterior episiotomies.

REPAIR. After delivery you may be asked to repair her introitus, so that it is narrow once more. If this is a cultural requirement, it may be kind to grant her her wish. On the other hand, she may may be anxious not to be sewn up, and resist your attempts even to sew up her posterolateral episiotomy, which must be repaired.