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Learning Objectives
Learning Objectives
Describe the types of FGM/C and their associated short- and long-term health risks, with emphasis on obstetric complications
Understand the sociocultural context and relevance of FGM/C for healthcare providers
Use a patient-centered, culturally sensitive approach to facilitate important healthcare decisions for survivors of female genital mutilation/cutting
Review evidence-based recommendations about providing obstetric care for survivors of type III FGM/C
Discuss principles for sensitively discussing FGM/C with patients
Introduction
Introduction
Female genital mutilation/cutting (FGM/C) comprises “all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.” Major global health bodies (World Health Organization, American College of Obstetricians and Gynecologists, Centers for Disease Control) use similar definitions and emphasize that FGM/C has no health benefits or medical justification for girls and women and constitutes a human-rights violation [1, 2, 3].
More than 230 million girls and women alive today have undergone FGM/C, and more than 4 million girls are estimated to be at risk of FGM/C annually [1]. Detailed national prevalence data is only available for 31 countries, but a recent report has collated evidence of female genital mutilation/cutting in 94 countries including the United States, United Kingdom, Australia, Canada, and New Zealand [4].
The World Health Organization (WHO) groups FGM/C into four major types [1]:
● Type 1 (clitoridectomy): Partial or total removal of the clitoral glans (external and visible part of the clitoris) and/or the prepuce/clitoral hood (fold of skin surrounding the clitoral glans).
● Type 2 (excision): Partial or total removal of the clitoral glans and the labia minora (inner folds of the vulva), with or without removal of the labia majora (outer folds of skin of the vulva).
● Type 3 (infibulation): Narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora, sometimes through intentional stitching, with or without removal of the clitoral prepuce/clitoral hood and glans.
● Type 4: Includes all other harmful procedures to the female genitalia for non-medical purposes, e.g., pricking, piercing, incising, scraping and cauterizing the genital area.
Immediate complications: severe pain, hemorrhage, genital tissue swelling, infection (e.g., tetanus), urinary retention, trauma, shock, and death [1,5]
Long-term physical sequelae: chronic vaginal and pelvic pain and infection, recurrent cystitis or urethritis, scarring, infertility, menstrual disorders, dyspareunia, obstetric complications (e.g., prolonged labor, perineal tears, excess hemorrhage during and after delivery, increased risk for C-section or need to resuscitate baby, neonatal and maternal mortality), psychological damage (e.g., anxiety, depression, low libido) [1,5,6]
Image from the Orchid Project
Qualitative studies and literature reviews emphasize that FGM/C is sustained by complex social norms and sociocultural factors, such as ideas about marriageability, gender and sexual norms, perceived hygiene or health benefits, and tradition [7]. The United Nations Spotlight Initiative emphasizes that while FGM/C is often wrongly perceived as a religious obligation, it has no foundation in faith [8]. Motivations range from psychosexual (controlling women’s sexuality) to cultural, aesthetic, and economic [8]. In some regions, FGM/C can be a prerequisite for the right to inherit, improve a woman’s marriage prospects, and provide a source of income for practitioners [8]. There is evidence suggesting involvement of health workers performing FGM/C due to the belief that the procedure is safer when medicalized [1]. The WHO has developed a global strategy against FGM/C medicalization and urges healthcare providers to reject and abandon FGM/C within their communities [1].
It is essential that clinicians receive training in the management of women who have undergone female genital mutilation/cutting (FGM/C) and approach care with cultural sensitivity. Each patient should be evaluated on an individual basis, without presuming their personal views on FGM/C, to maintain trust and uphold the integrity of the physician–patient relationship.
Case Introduction
You are a fourth-year medical student rotating on labor and delivery triage in the emergency room. Your preceptor Dr. Garcia requests that you see a new patient, Nora, a 24-year-old woman G1P0 who is screaming in pain with contractions every 3 minutes. You do some preliminary chart review beforehand and discover there is no prior medical documentation on record for this patient.
Taking a History
Taking a History
After introducing yourself to Nora, you begin by asking her about her concerns today.
You: What brings you in today, Nora?
Nora: I’ve been having really strong pains in my belly. They’ve been coming about every three minutes, and I think I might be in labor.
You: I’m so sorry to hear that, Nora. It sounds like you may be having contractions - can you tell me more about what the pains feel like?
Nora: They’re very intense and spread across my whole belly. They last about a minute, then go away and come back again.
You: When did these contractions start?
Nora: They started a few hours ago and have been getting stronger and closer together.
You: Have you noticed any leaking fluid or vaginal bleeding?
Nora: No, I haven’t seen any blood or fluid.
You: Is the baby moving normally?
Nora: Yes, I’ve been feeling the baby move.
You: Do you know your due date or when your last menstrual period was?
Nora: No, I don’t know my exact dates. I think I am about 8 months pregnant.
You: Have you had any prenatal care during this pregnancy? Any ultrasounds?
Nora: No, I did not go to a clinic. I never had any problems during this pregnancy, so I did not think about going.
You thank Nora for coming into the hospital and sharing her concerns. You finish obtaining the rest of the history and a pertinent review of systems. You learn that:
Nora moved to the United States two years ago from East Africa. She lives with her husband and his extended family (mother and father) and feels safe at home.
This is her first pregnancy. She has never seen a doctor before and has had no prenatal care.
She has no known medical or surgical history. No family history of pregnancy complications, congenital anomalies, or chronic conditions such as HTN, diabetes, or clotting disorders that she is aware of. She takes no medications and has no known medication allergies.
She reports that she does not smoke, drink alcohol, or use any substances.
She has not noticed any other health concerns during pregnancy aside from occasional back pain.
Review of systems: Positive for regular, painful contractions occurring every 3 minutes. She denies fever, chest pain, or shortness of breath. She reports feeling ongoing fetal movement.
You: Okay, I’m going to feel your belly to check how far along you might be. Is that ok with you?
Nora: Yes, please check my baby.
Physical Exam
Your physical exam reveals the following:
Vitals: T 98.6°F, HR 110, BP 130/78, RR 22, SpO₂ 99% on room air.
General: Appears in moderate distress due to labor pain. Sitting upright on the examination table, clutching abdomen, actively moaning with contractions.
Neurological: Alert and oriented to person, place, and time. Cranial nerves II–XII grossly intact.
Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops.
Respiratory: Lungs clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
Abdominal/Obstetric: Abdomen gravid. Firm, frequent contractions palpated every 3 minutes. Fetal head palpable in the lower uterine segment, above pelvic brim, not engaged. No rebound tenderness or guarding.
Extremities: edema. Full range of motion bilaterally.
Skin: Warm, dry, intact. No rashes or lesions noted.
You measure fundal height by gently palpating the top of the uterus (fundus) then placing a tape measure from that point down to the upper border of the pubic symphysis. Generally, the fundus is at the level of the umbilicus at around 20 weeks gestation and above the umbilicus at 24+ weeks gestation. Her fundal height is about 35 centimeters, which suggests she is in the third trimester.
You request Nora’s permission to assess for fetal heart tones and note a fetal heart rate in the 140s. You reassure her that that is normal and start her on continuous fetal monitoring. You establish IV access and order a CBC, type & screen, and urinalysis.
Question
What kind of work-up would you suggest for this patient?
A: Pelvic ultrasound
B: Pelvic MRI
C: Pelvic exam
D: CT abdomen and pelvis with contrast
E: A & C
F: C & D
Answer (Highlight the following text for the answer - text in white font): The answer is A&C - pelvic ultrasound and pelvic exam. Dr. Garcia: Since this patient has never been evaluated before during her pregnancy, she requires a pelvic ultrasound to provide a biometric estimate of fetal gestational age and assess fetal presentation, fetal heart tones, amniotic fluid volume, and placental location. A pelvic exam is necessary to evaluate her cervix and assess for dilation, effacement, and fetal station.
You speak to Nora about the need for a pelvic ultrasound and pelvic exam and acknowledge her pain and distress. She consents to both procedures and asks for only female personnel to be present in the room during her pelvic exam.
Dr. Garcia and you perform a gentle pelvic exam with a female nurse (that Nora feels comfortable with) present to chaperone. You tell Nora, “I’m going to gently examine you now to check your cervix and see how far into labor you are. You let us know at any time if anything is uncomfortable or painful, and we will immediately stop.” Your findings are as follows:
General: No obvious infection, discharge, or bleeding.
External genitalia: Significant scar tissue across the vulvar region. Labia minora and labia majora partially fused, forming a narrow vaginal introitus. Urethral meatus visible and patent.
Vaginal canal: Narrow, fibrous band of tissue partially occluding vaginal opening. Vaginal mucosa distal to scar appears healthy. Cervix not fully visualized on exam due to scarring; full digital cervical assessment deferred.
Perineum: Scarred and firm. No active lesions or ulcerations.
After leaving the room to allow Nora to get comfortable, you and Dr. Garcia discuss and debrief the encounter.
Exam Results and Next Steps
Exam Results and Next Steps
Dr. Garcia: “What did you notice on the exam?”
You: “The labia are partially fused, and the vaginal opening is narrow. The cervix isn’t fully visible."
Dr. Garcia: “Right. These findings are consistent with Type III FGM/C. What implications does this have for her care?”
You: “There may be difficulty with cervical assessment and vaginal delivery without deinfibulation. We also need to be mindful of preterm labor at 35 weeks.”
Question:
What is deinfibulation and what are indications for its use in labor?
Answer (Highlight the following text for the answer - text in white font): Deinfibulation is a surgical procedure to open the narrowed vaginal opening in women who have undergone type III FGM/C (infibulation). It involves performing an incision of the midline scar tissue that covers the vaginal introitus until the external urethral meatus, and eventually the clitoris, are visible [9]. It is recommended for preventing and treating obstetric complications in women living with type III FGM/C [9].
Indications for deinfibulation in labor:
-Prior to instrumental delivery or episiotomy (i.e., to allow for instrument placement or surgical repair)
-Relief of urinary or menstrual problems (e.g., obstructed flow)
-To allow for safe passage of baby in vaginal delivery - narrowed introitus can lead to obstructed labor, perineal tears, increased risk of need for emergency C-section
It can be done electively during pregnancy (usually in the second trimester) to reduce trauma and pain during labor.
WHO summary of recommendations and best practice statements for deinfibulation: [9]
While there is strong observational evidence that deinfibulation reduces many risks, high-quality randomized controlled trials are rare, so many recommendations are conditional. WHO grades the evidence for deinfibulation in type III as conditional with low certainty evidence [10]. Given the health risks of type III FGM/C, there was consensus among the WHO Guideline Development Group that the benefits of deinfibulation for pregnant women with type III FGM/C outweigh any harms even though the certainty of the evidence from most studies was very low [10].
Question: How does type III FGM/C alter preterm labor workup?
Answer (Highlight the following text for the answer - text in white font): Cervical assessment can be limited due to scar tissue - so a full cervical exam (dilation, effacement, fetal station) is often deferred until deinfibulation.
-Pelvic exams should be modified to minimize trauma and may require analgesia or anesthesia for adequate pain control.
-Pelvic ultrasound - particularly transabdominal - becomes more important in assessing fetal presentation, growth, amniotic fluid, and approximate gestational age.
Workup is otherwise unchanged with standard obstetric labs and continuous fetal monitoring.
Dr. Garcia: “Exactly. Remember, our approach needs to be safe and culturally sensitive. Let’s talk about how we can involve her in decisions and explain procedures without judgment.”
Discussion with the Patient
Discussion with the Patient
Healthcare providers are recommended to create a safe, neutral environment that does not impose any prior biases or moral judgements about the practice (whether positive or negative) onto the patient. Let the patient tell you where they stand and allow them to direct the conversation. Always use the same words your patient relies on to describe their experience with FGM/C. Mirror their language!
You and Dr. Garcia head back into the room to discuss further with Nora.
Dr. Garcia: Hi Nora, thank you for letting us take care of you. I want to talk with you about something we found on your exam, and then we can discuss the plan for your labor. Does that sound okay with you?
Nora: Yes.
Dr. Garcia: During the exam, we noticed that the genital tissue has been partially closed. Is this something you feel comfortable talking more about?
Nora: Thank you for asking me first. It’s a long story, and I’m not sure where to start.
Dr. Garcia: I completely understand, and we will only talk about it if you feel comfortable. I understand this is a sensitive topic and want to let you know that any information you share will be kept confidential.
Nora: Thank you, Dr. Garcia. I want to make sure my baby is safe, and I feel comfortable sharing.
After a lengthy conversation, Nora shares that she was ‘cut’ when she was 8 years old. She was taken by a family member into a “basement clinic,” where she was forcibly held down and cut. She remembers being soaked in blood and in so much pain that she blacked out for days after. She notes there are many names for this procedure in her culture, but she prefers the term “female circumcision.” She understands there is no relation to male circumcision; however, that is the word she feels comfortable with. She still feels the intense pain in her pelvic area and has struggled with sex for years. It also took a long time for her to be able to trust her husband as she still feels betrayed by the family members that partook in the practice.
Question:
In keeping with culturally sensitive care, what principles should you abide by when discussing FGM/C with your patient? (Short answer)
Answer (Highlight the following text for suggested answers - text in white font): Suggested answers [11]: Do: mirror the language your patient uses when describing their experience with FGM/C, ask your patient if they’re willing to talk about FGM/C, limit the number of providers in the room when examining the patient, use a non-judgmental tone and keep an open mind, provide interpreter or translator services when needed, ask if your patient would like to be accompanied by family members
Do NOT: use the word “mutilation” with your patient, insist on discussing FGM/C if your patient does not want to, let a family member serve as interpreter/translator, react with shock or horror, invite other providers in the middle of a vaginal exam, assume the patient will bring up FGM/C or are unhappy living with FGM/C (some may see consequences such as painful periods or infections as a normal part of life), treat FGM/C as an educational opportunity without permission, discuss FGM/C with family members in the room unless the patient brings up FGM/C first, assume your patient knows FGM/C is illegal in the United States, assume your patient will seek out mental health or specialist services on their own.
Cultural sensitivity and awareness are essential when dealing with FGM/C. A qualitative study of a Somali community in the United Kingdom demonstrated some women felt re-traumatized by health providers who inappropriately questioned or probed patients based on cultural stigma [11]. They noted this stigmatization was also seen in non-clinical settings like school, leading to feelings of fear and alienation [11].
The George Washington University clinical toolkit on caring for survivors of FGM/C provides patient testimonies on advice to healthcare providers [11]:
Assessment and Plan
Assessment and Plan
You and Dr. Garcia discuss all the findings with Nora, including her labs and pelvic ultrasound which showed a normal intra-uterine pregnancy consistent with an estimated gestational age consistent with her exam.
Dr. Garcia: Thank you, Nora, for sharing your experiences with us. I want to explain how your female circumcision might affect your labor and the steps we can take to ensure your safety and comfort.
Nora: I see. What does that mean for me now?
Dr. Garcia: Given the narrowing, we may need to perform a procedure called deinfibulation. This involves carefully opening the vaginal area to allow the baby to pass through safely. We would do this during labor, just before delivery.
Nora: Will it hurt?
Dr. Garcia: We will use local anesthesia to numb the area, so you shouldn’t feel pain during the procedure. We can also provide sedation if you prefer not to be awake during the procedure. Your safety and comfort are our top priorities.
Nora: I understand. What happens after the baby is born?
Dr. Garcia: After delivery, we do not recommend reinfibulation but we can talk together about reconstructive options that may support your health and personal goals. We also want you to know that your emotional wellbeing matters just as much as your physical recovery. Many women find this experience brings up strong and sometimes complicated feelings, and we will make sure you have access to counseling and support if you would like it.
Nora: Thank you for explaining. I appreciate your support.
Dr. Garcia: You’re very welcome, Nora. We’re here to support you every step of the way. If you have any questions or need anything, please let us know.
Case Reflection
Case Reflection
You and Dr. Garcia return to her office for a moment to allow Nora to process the discussion. You remember how calm and composed Dr. Garcia was during the patient encounter and ask her how she balances urgent clinical needs with sensitivity and respect.
Dr. Garcia: When I realized Nora had undergone type III FGM/C, my first reaction was surprise and concern. However, I wanted to ensure the focus was on keeping Nora and her baby safe. Even in urgent settings, I always maintain a non-judgmental tone and check for my patients’ understanding and comfort frequently.
You: Of course. This case helped me see that though FGM/C has serious health consequences, it’s also tied to cultural and social factors I may not fully understand. I want to practice cultural humility by listening to my patients’ perspectives and make sure they feel heard and respected, even during emergencies.
Dr. Garcia: Yes, and though our patient was fluent in English, we must always keep language barriers in mind. It’s important to have an interpreter or translator available for our patients who may need them.
Question:
Write a few sentences capturing your thoughts on what you learned about FGM/C and the importance of cultural humility and awareness in clinical practice (Short answer)
Following Up
Following Up
Six months later, Nora returns to the hospital and asks to see Dr. Garcia. She is pleased to see you there. She mentions that her healthy baby girl, Layla, has been a joy and that sharing her experiences with you and Dr. Garcia has been helpful. After her deinfibulation during delivery, her urination has improved, and she has noticed fewer episodes of vaginal and urinary tract infections. She is also in therapy and has also started an anti-depressant to support her mental health. She thanks you and Dr. Garcia for listening and being so supportive during her labor and delivery. You wish her well and encourage her to continue following up regularly with her health providers, reminding her that she is not alone in her recovery and that her health and well-being remain a priority.
References
References
World Health Organization. Female Genital Mutilation. World Health Organization. Published January 31, 2025. https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation
Female Genital Mutilation. Acog.org. Published 2022. https://www.acog.org/clinical-information/policy-and-position-statements/statements-of-policy/2022/female-genital-mutilation#Reference2
CDC. Female Genital Mutilation/Cutting (FGM/C). Reproductive Health. Published May 20, 2024. https://www.cdc.gov/reproductive-health/women-health/female-genital-mutilation-cutting.html
New report finds female genital mutilation/cutting in 94 countries. End FGM. Published 2025. https://www.endfgm.eu/news-en-events/press-releases/new-report-finds-female-genital-mutilationcutting-in-94-countries
Sarayloo K, Latifnejad Roudsari R, Elhadi A. Health Consequences of the Female Genital Mutilation: A Systematic Review. Galen medical journal. 2019;8(1):e1336. doi:https://doi.org/10.22086/gmj.v8i0.1336
World Health Organization. Family and Community Health Cluster. A Systematic review of the health complications of female genital mutilation including sequelae in childbirth. Whoint. Published online December 31, 2000. doi:https://doi.org/WHO/FCH/WMH/00.2
Berg RC, Denison E. A Tradition in Transition: Factors Perpetuating and Hindering the Continuance of Female Genital Mutilation/Cutting (FGM/C) Summarized in a Systematic Review. Health Care for Women International. 2013;34(10):837-859. doi:https://doi.org/10.1080/07399332.2012.721417
Five myths about female genital mutilation. www.spotlightinitiative.org. Published February 6, 2020. https://www.spotlightinitiative.org/news/five-myths-about-female-genital-mutilation
World Health Organisation. WHO Guidelines on the Management of Health Complications from Female Genital Mutilation I.; 2016. https://iris.who.int/bitstream/handle/10665/206437/9789241549646_eng.pdf?sequence=1
WHO. Recommendations and best practice statements. Nih.gov. Published 2025. https://www.ncbi.nlm.nih.gov/books/NBK614880/
How do I discuss FGM/C with my patient? | FGM/C Educational Toolkit Project | The George Washington University. FGM/C Educational Toolkit Project. Published 2019. https://fgmtoolkit.gwu.edu/health-care-providers/how-do-i-discuss-fgmc-my-patient
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