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Bridging the Gap: 

The Urgent Need for National Labor Guidelines for Persons with Female Genital Mutilation/Cutting

Hannah Panzica 1 and Bhavika Garg 1

1 Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York

Introduction

  • Female genital mutilation/cutting (FGM/C) refers to all procedures involving partial or total removal of the external female genitalia for non-medical reasons.
  • More than 230 million girls and women are currently living with its consequences, including up to 513,000 women in the U.S. alone (1, 2).
  • Obstetricians and gynecologists (OB/GYNs) and primary care providers are increasingly likely to encounter patients affected by FGM/C.
  • Linked to adverse obstetric outcomes.
    • No clinical guidelines currently exist from the Centers for Disease Control and Prevention (CDC) or the American College of Obstetricians and Gynecologists (ACOG), and physician training remains limited. 

Objective

  • Understand the gaps in national labor and delivery guidelines for patients affected by FGM/C in the U.S.
  • Propose action and tenets of evidence-based care.

Figure A. FGM/C involves the partial or complete removal of external female genitalia for non-medical, and often sociocultural reasons, primarily practiced in parts of Africa, the Middle East, and Asia (3).

Figure B. The Population Reference Bureau’s graph highlights the number of women and girls at risk of FGM/C in the U.S., emphasizing the need for providers to be informed and prepared to manage such cases (4).

Current Guidelines

ACOG: Condemns FGM/C and acknowledges its cultural context and prevalence but provides no guidance on treatment or patient-centered communication (8).

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CDC: Summarizes the sociocultural factors, prevalence, and health burden associated with FGM/C (9). 

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American Academy of Pediatrics: Clinical history-taking and long-term complications (sexual dysfunction and infertility). Includes L&D considerations for teenagers with FGM/C with recommendations of timing of de-infibulation (10). 

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RCOG: Comprehensive clinical recommendations for the management of FGM/C: outlining legal responsibilities, referral pathways, and guidance/methods for de-infibulation across antenatal, intrapartum, and postpartum care (11).

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SOGC: Comprehensive clinical recommendations including pelvic floor therapy (dilators), procedural guidance for de-infibulation, and possibility of concurrent episiotomy during L&D (12).

Proposed Tenets of Care

Each patient should be evaluated on an individual basis, without presuming their personal views, to maintain trust and uphold the integrity of the physician–patient relationship.

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  • The essential first step in care is accurate identification and documentation of the type and extent of FGM/C. This determination guides subsequent management, counseling, and procedural planning.

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  • De-infibulation is recommended during the second trimester under spinal anesthesia, allowing adequate time for neo-vulvar healing prior to labor. May be performed up to 34 weeks’ gestation (13).

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  • If performed intrapartum, an episiotomy performed concurrently may facilitate delivery, minimize vaginal tearing, and facilitate pelvic examinations, urinary catheterization, and intrapartum monitoring (12).

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  • Arranging for appropriate follow-up care with frequent monitoring, annual gynecological exams, possible referrals to mental health counseling, and consideration for post-partum follow up visit sooner than 6 weeks.

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  • Pelvic floor therapy, including vaginal dilators, may be used for improving sexual function and preventing further adhesions/scarring (12). 

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Conclusion

  • Increasing prevalence of FGM/C in the U.S. underscores the urgent need for standardized, evidence-based clinical guidelines and physician education. 

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  • FGM/C represents a growing public health concern due to increased global migration, the long-term physical and psychological sequelae associated with the practice, and the current lack of provider preparedness across specialties to address these needs in clinical settings.

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  • It is essential that clinicians receive training in the management of individuals who have undergone female genital mutilation/cutting (FGM/C) and approach treatment with cultural sensitivity and trauma-informed care.

The Human Rights Initiative

University at Buffalo Jacobs School of Medicine and Biomedical Sciences

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hpanzica@buffalo.edu

bgarg@buffalo.edu

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What is FGM/C?

Common Complications

Illegal in U.S. - Why So Prevalent?

FGM/C is sustained by complex social norms and sociocultural factors:

  • Ideas about marriageability
  • Gender and sexual norms
  • Perceived hygiene or health benefits, and tradition (6).

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While FGM/C is often wrongly perceived as a religious obligation, it has no foundation in faith. 

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Motivations range from: 

  • Psychosexual (controlling women’s sexuality), cultural, aesthetic, and economic.
  • Prerequisite for the right to inherit, improve a woman’s marriage prospects, and provide a source of income for practitioners (7).

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There is evidence suggesting involvement of health workers performing FGM/C due to the belief that the procedure is safer when medicalized (2).

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WHO has developed a global strategy against FGM/C medicalization and urges healthcare providers to reject and abandon FGM/C within their communities.

References

Figure C. Image from The Orchid Project highlighting the major complications of FGM/C experienced throughout life (5).