Health Impacts of Female Genital Mutilation/Cutting: A Synthesis of the Evidence

"Female genital mutilation/cutting (FGM/C) continues to be a threat to women’s and girls’ health and human rights globally. A sizeable body of evidence has developed over  the past three decades on the direct health impacts of FGM/C. However, the evidence has been spread out and detached in diverse research, interventional, and training materials, making it cumbersome for quick reference when responding to women and girls exposed to the health effects of FGM/C."

This report synthesises the evidence on the health impacts of ending female genital mutilation/cutting (FGM/C), identifies recommended interventions, and compiles and analyses existing reference materials intended for health care providers. The goal of this review is to inform the development of a comprehensive set of training guidelines and materials for frontline health care providers so they can manage the care of women and girls who have undergone FGM/C, prevent the practice at the community level, and accelerate abandonment of FGM/C practices. The report forms part of the Evidence to End FGM/C: Research to Help Girls and Women Thrive project, which seeks to generate evidence to inform and influence investments, policies, and programmes for ending FGM/C in different contexts. The intended audience for these findings include policymakers, programme implementers, and researchers.

The report highlights five categories of health impacts:

• Sexual complications are associated with FGM/C as women who had undergone cutting were more likely to report painful intercourse, no sexual desire, less sexual satisfaction, and fewer orgasms compared to their uncut counterparts.
• The practice or its delayed complications may trigger the onset of one or a combination of the following complications: acute anxieties, depression, neuroses, psychoses, and post-traumatic stress disorder. The physical complications arising from FGM/C may also interfere with women’s and girls’ social lives because of ill health.
• The evidence on the magnitude of immediate complications associated with FGM/C varied across the reviewed studies. This variation may have been due to under-reporting of the complications or to the timing of post-procedure observations. Such disparities may be the result of differences in data collection, with clinical assessment likely to be more objective and accurate, while self-reporting may result in gross under-reporting. This is supported by the fact that many women underwent FGM/C as infants or children and may not remember any immediate adverse effects or link the complications arising later in life to the genital cutting they underwent as children.
• Female genital cutting is associated with chronic problems affecting the genital and/or urinary systems of women and girls including genito-urinary problems commonly reported include: genital tissue damage, vaginal discharge, itching, urological complications, and infections. This linkage has been corroborated by several studies involving large numbers of women and girls.
• The obstetric complications, notably prolonged labour, tears and lacerations, caesarean sections, episiotomies, instrumental deliveries, postpartum haemorrhages (PPHs), and difficult labour associated with FGM/C were documented by numerous studies involving large samples of women and girls.

Beyond explaining the health impacts of FGM/C, this analysis points to the need to strengthen health care workers' capacity to deal with the health consequence of FGM/C, as well as the kind of interventions that are required. The report then goes on to explore the evidence related to curative and preventive interventions for alleviating and preventing FGM/C-associated complications, both in health facilities and in socio-community settings. These interventions are categorised as follows:

• the training of health care professionals; the provision of counselling and psycho-social support; social conventions and norms and creating awareness; the strengthening of health systems; and the need for documentation and research. 

The report includes a list of recommendations for each intervention area. These recommendations are informed by best practices based on study reports, experts, and the strength of the available evidence.

Due to their relevance to behaviour change and communication, only the findings and recommendations related to addressing social conventions and norms and creating awareness are highlighted. As stated in the report, “Health care providers play a key role in raising people’s awareness, bringing attention to the health impacts of FGM/C and encouraging behaviour change in the social conventions and norms that underpin the practices of FGM/C.” The recommended actions highlighted in the report suggest the need to:

• “Enhance capacity of health care providers to raise awareness of the health impacts associated with FGM/C and encourage them in their roles as advocates, role models, counselors, and caretakers to contribute to the mitigation and abandonment of the practice.
• Anchor FGM/C preventive messages to existing reproductive health programs in health facilities, as well as in community settings, which will go a long way towards prevention and management of these complications.
• Familiarize all maternity healthcare providers with the nature and higher rates of complications related to FGM/C.
• Encourage women and girls to seek medical care if they have complications, because such complications may become intensified or even cause death, and also encourage them to avoid traditional remedies because the use of herbs can lead to severe bleeding or introduction of infections.
• Support health care providers in establishing community approaches to dealing with consequences of FGM/C (e.g., community psycho-social support, debriefings, and establishment of networks).
• Sensitize communities to the fact that some of the reproductive and medical complications women and girls present with at health service points are associated with FGM/C and that they can be traced to childhood trauma such as FGM/C. Raising awareness in this manner would enhance identification of the complications and lead to better-health seeking behaviour and promotion of preventive strategies.
• Involve local administration, law enforcement, prosecutors, and the judiciary in raising awareness in communities about anti-FGM/C laws and the consequences of breaking these laws, and increasing knowledge about prosecutions and penalties.
• Lay the foundation for norm change by educating communities and professionals that FGM/C is a violation of human rights and raising community awareness about the global instruments against FGM/C, notably the United Nation General Assembly and Human Rights Council of 2012 and 2014 resolutions.
• Undertake concerted educational interventions involving all stakeholders on the facts about FGM/C, thereby counteracting myths that are used to perpetuate the practice, such as “FGM/C is supported by religion,” and “the practice makes woman more fertile,” among others.
• Dissociate FGM/C from religion by involving religious leaders and the community through capacity building.
• Partner with communities to develop abandonment strategies for FGM/C, including participation in documentation, anonymous reporting, monitoring, and tracking of the FGM/C practice.
• Encourage traditional excisors to abandon the practice and empower them to obtain income from other means.
• Empower women and girls through economic opportunities, education for the girl child, and dissociation of FGM/C from dowries.
• Establish anti-FGM/C campaigns among community structures and formal institutions like schools and churches to accelerate abandonment.
• Involve both men and women in the fight against FGM/C, helping them to associate the practice with its health consequences and thereby accelerating its abandonment.”

The report reviewed existing training and reference research materials on FGM/C management and found various types of gaps in the materials. The analysis showed that the background information, including the epidemiology of FGM/C was strong but materials “scored marginally on physical, gynecological, and obstetric complications. In addition, the reference materials scored poorly on the sexual and psycho-social impacts of FGM/C. Curative and preventive interventional approaches are recommended in the review for the various health consequences.” The report outlines a number of recommended interventions in order to enhance training, programming, and messaging for medical care providers such as: establishing referral systems where expert care is lacking, strengthening care systems to respond to FGM/C challenges, and building the capacity of frontline health care professionals to enable them to offer curative and preventive services in FGM/C-prevalent areas. Many of the recommendation above related to addressing social conventions and norms and creating awareness are also reflected in the recommended goals and messages for the development of training materials.

The report concludes by pointing out that “women’s health is a human rights issue and women’s empowerment cannot be separated from issues related to women’s health. Therefore, a comprehensive, user-friendly training guide is required.” Moving forward, the Evidence to End FGM/C: Research to Help Girls and Women Thrive programme plans to review existing curricula and related materials for health professionals to inform the development of much-needed training materials and guidelines for health care providers; and to conduct further research to deepen understanding on all the health impacts of FGM/C including their management and prevention.