When medical providers hear the term female genital mutilation/cutting(FGM/C), they may think of women in foreign countries who present in childbirth with FGM/C and that it is an adult gynecologic issue.
In fact, this is not the case.
FGM/C is a pediatric practice not linked to any religion, ethnicity or race and predates Jewish, Christian and Islamic religions. Although outlawed in much of the world, it continues to be practiced in 30 countries in Africa, the Middle East, as well as in regions of Southeast Asia. While it also is illegal in the U.S., there have been reports of pediatric cases here.
A new AAP clinical report is the first comprehensive summary of FGM/C in children and includes education on a standard of care approach for examination of external female genitalia at all health supervision visits. The report,Diagnosis, Management and Treatment of Female Genital Mutilation/Cutting in Girls from the Section on International Child Health, Committee on Medical Liability and Risk Management and Committee on Bioethics, is available at https://doi.org/10.1542/peds.2020-1012 and will be published in the August issue of Pediatrics.
Definition, customs, complications
FGM/C involves medically unnecessary cutting of parts or all of the external female genitalia, including the clitoris, prepuce, labia minora and labia majora. It is associated with short-term morbidity, including hemorrhage, sepsis and urethral injury, and death. Long-term complications include chronic urinary tract infections, fibrosis, dysmenorrhea and dyspareunia.
There are four types and sub-types, with type 3 having the most tissue removed and, thus, resulting in the most associated morbidity and mortality. ICD-10 codes currently exist only for the four main types.
FGM/C has no medical indication or benefit, and beliefs regarding the practice include that it ensures marriageability, improves hygiene and/or perpetuates a traditional rite of passage.
The practice usually is performed in girls from infancy through puberty, depending on cultural beliefs and region of the world, and mostly is done by designated lay health workers.
In 2018, the United Nations Children’s Fund estimated that 200 million girls and women alive at that time had undergone FGM/C. Some experts estimate that over 500,000 girls and women in the U.S. have had FGM/C or are at risk of cutting.
Lack of training, examinations
No training regarding FGM/C is required for medical students, residents or continuing medical education for physicians. Training standards and requirements do not exist for general pediatricians, child abuse pediatricians, pediatric urologists, pediatric gynecologists, adolescent medicine physicians or pediatric emergency department physicians — all of whom may provide medical care for affected girls.
In a recent regional survey of general pediatricians who were asked about their approach to external genital examinations of girls at well-child visits (n=62), the age of the child was inversely proportional to the frequency of external genital examinations. Results showed 75% reported examining newborns; 68%, ages 6-12 months; 45%, 13-months-2-years; 18%, 5-8 years; 11%, 13-16 years; and 8%, 17-18 years (Young J, et al. J Immigrant Minority Health. 2019; https://doi.org/10.1007/s10903-019-00938-x).
Some experts believe that the presumed lack of standard examination of external genitalia has led to unfamiliarity with normal examination findings, variations of normal findings, a lack of identification of affected girls, as well as a presumed difficulty with identifying FGM/C types and sub-types. FGM/C sub-types may be easily missed, both in pre-pubertal girls where structures are less developed, as well as in pubertal girls, where some sub-types have more subtle findings.
Some have suggested that only girls who come from affected countries should have external genital examinations at well-child visits. However, all girls — U.S.-born or otherwise — may have diagnoses of importance, including lichen sclerosis, labial adhesions and/or signs of child abuse.
The practice of FGM/C in the U.S. is illegal. FGM/C performed in another country before immigration to the U.S. is not reportable or prosecutable; however, transporting a child out of the U.S. for FGM/C is illegal. Health care providers who are unsure of state and federal laws related to FGM/C can consult a local child abuse pediatrician.
A history of FGM/C or risk for FGM/C are grounds for asylum status in girls and their parents. If a girl and/or her mother has FGM/C or is at risk, it is recommended to link them to legal counsel for support in applying for legal status, if appropriate.
Clinical history-taking around FGM/C should be standard practice for pediatricians who care for girls with possible risk factors for FGM/C, including those having a mother or sibling with FGM/C, country of origin and/or birth country, and/or history of travel to a country where FGM/C is practiced. While this may seem daunting, once rapport and trust have been established, discussions may occur with relative ease and can include statements as the following:
I am learning about cultural practices in your country and understand that female genital cutting still happens there. As a physician, I know that female genital cutting may have severe medical complications, and I want to make sure that you and your daughters are not having these issues because they can be treated. I also want to make sure you understand that it is illegal to have a girl cut once she is living in the U.S. This includes not sending her to another country to have her cut once she has been living in the U.S.
- FGM/C is illegal in the U.S., has significant morbidity and mortality, has no medical benefit and should never be performed.
- Medical providers caring for girls at risk for FGM/C should counsel families against performing FGM/C, including when families travel to countries where FGM/C is practiced.
- National training standards and requirements regarding FGM/C need to be built into curricula for all medical providers.
- Standard of care for all well-child examinations from birth through adulthood should include examination of female external genitalia, including identification of clitoris, prepuce, labia minora and labia majora. This allows for identification of FGM/C and other diagnoses of significance.
- FGM/C or risk of FGM/C are grounds for asylum status, and girls should be linked to legal counsel when appropriate history is obtained.
Dr. Young is a lead author of the clinical report.