Over the last couple of months, there has been a national debate on the appropriateness of female genital cutting in The Gambia. Most of the discussion have focused on personal opinions of interested stakeholders on the topic. As gynaecologists and doctors working in women’s health, this is our contribution to the discussion.
Female genital cutting is currently performed in The Gambia by practitioners with no formal medical training without anaesthesia and often using crude instruments in environments that do not meet the minimum health and safety standards.
Modern medical practice has moved beyond the opinion of respected authorities to evidencebased medicine. In the hierarchy of evidence-based medicine, the opinion of respected authorities in the field is rated much lower than peer-reviewed observational studies. The highest level to source for evidence is systematic reviews and meta-analysis. There have been several systematic reviews and meta-analysis on the health effects of female genital cutting (Saryloo et al 2019). Professionals may have their individual opinions about female genital cutting but it cannot supersede observational studies or systematic reviews.
Because of the way in which female genital cutting is performed, there is immediate risk of significant bleeding, injury to vital organs like the urethra, infection and fever. In a systematic review by Berg (Berg 2014), the most common immediate complications were bleeding, acute inability to urinate and swelling around the genital area.
Long term health consequences of female genital cutting have also been well documented. Genital scarring and neuromas of the clitoris causing severe pain have been described in The Gambia by Kaplan as well as in other studies (Kaplan 2013). Several of us practicing in the Gambia have had to surgically remove large masses (epidermoid inclusion cysts and sebaceous cysts) caused by female genital cutting. Such swellings have been reported in the literature as well (see Asante et al 2010). In Berg’s systematic review, urinary tract symptoms and impaired sexual functions were significantly related with female genital cutting (see also Alsibiani 2010).
In a large study conducted by the World Health Organization (WHO) in 6 African countries that studied 28,000 women, female genital cutting was associated with more haemorrhage, increased risk of caesarean section, still birth and excessive bleeding after childbirth (WHO 2006). The findings from this large study are similar to a local observational study done in the Gambia by Idoko et al (Idoko 2022). Berg et al in a meta-analysis reported an increased risk of prolonged labour, postpartum haemorrhage and perineal trauma (Berg 2012).
Most of us practicing in The Gambia have also reported psychological problems associated with female genital cutting. Anxiety, flashbacks and post-traumatic stress disorder have been reported in women with female genital cutting (Vloeberghs2012). As a society we must not minimize the mental health of women.
Some have advocated that type 1A female genital cutting (hoodectomy or removal of the prepuce) is harmless and even beneficial and should be practiced within the healthcare system in The Gambia akin to male circumcision. We must note that we have not found robust research for the benefit of type 1A female genital cutting (hoodectomy). The external genital in a female infant is very small and the anatomic structures may be quite difficult to delineate. The risks associated with performing this procedure in children is therefore significant even in a hospital environment.
Clitoral hood reduction surgery (hoodectomy) belongs to a group of surgical procedures referred to as female genital cosmetic surgery. While consenting adult women who choose to have removal of the clitoral hood (type 1A) may have the freedom to do so by properly trained physicians, we align ourselves with the statement of the American College of Obstetricians and Gynaecologists (ACOG) on female genital cosmetic surgery. The 2020 ACOG statement concludes that this procedure is not medically indicated, poses substantial medical risk and their safety and effectiveness have not been established. Moreso, we are concerned about the strain that will be added to our already burdened public healthcare system if hoodectomy is practiced in our public health facilities. In fact, resources will have to be diverted from other life-saving services to cater for hoodectomy in our public health system. Therefore, this may lead to public harm in the long run.
A fundamental principle of medical ethics is to do no harm. We believe it will be unethical for any physician to perform female genital cutting. We will therefore urge the law makers to leave the current laws on female genital cutting as it is. If any part of this law is amended, significant harm to the anatomy and mental health of women is inevitable.
This statement is endorsed by the following:
1. Dr. Patrick Idoko Senior Consultant Gynaecologist
2. Dr Hassan Azadeh Senior Consultant Gynaecologist
3. Dr Mustapha Bittaye Senior Consultant Gynaecologist and Director of Health Services
4. Dr Matthew Anyanwu Senior Consultant Gynaecologist
5. Dr Jose Green Harris Specialist Gynaecologist and Head of Clinical Services at Kanifing General Hospital
6. Dr Awa Jah Specialist Gynaecologist
7. Dr Fatoumata Jarjusey Specialist Gynaecologist
8. Dr Kebba Gassama Specialist Gynaecologist
9. Dr Dado Jabbie Specialist Gynaecologist and Head of Department at Bundung Maternal and Child Health Hospital
10. Dr. Barrister Babanding Daffeh Senior Medical Officer and Head of Department at Kanifing General Hospital
11. Dr Lucas Jatta Senior Medical Officer Brikama District Hospital
12. Dr Elizabeth Innis Gynaecologist
13. Dr Awa Sanyang Gynaecologist
Notes:
1. Saryloo K, Roudsari RL, Elhadi A. Health consequences of the female genital mutilation: a systematic review. Galen Med Journal.2019.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8343977/#
2. Berg RC, Underland V, Odgarrd-Jensen J, Fretheim A, VistGE. Effects of female genital cutting on physical health outcomes: a systematic review and meta-analysis. British Medical Journal Open 2014;4:e006316
3. WHO study group on female genital mutilation and obstetric outcome. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet. 2006;367:1835-41
4. Idoko P, Armitage A, Nyassi MT, Jatta L, Bah N, Jah A, Jabbie D, Bittaye M. Obstetric outcome of female genital mutilation in The Gambia – an observational study. Afri Health Sci. 2022;22(4). 386-395. https://dx.doi.org/10.4314/ahs.v22i4.44
5. Kaplan A, Forbes M, Bonhoure I, Utzet M, Martin M, Manneh M, et al. Female genital mutilation/cutting in The Gambia: longterm health consequences and complications during delivery and for the newborn. International journal of Womens Health 2013;5:323-31
6. Asante A, Omurtag K, Roberts C. Epidermal inclusion cyst of the clitoris 30 years after female genital mutilation. Fertil Steril2010;94:1097.e1-3
7. Berg RC, Denison E. Does female genital mutilation /cutting (FGM/C) affect women’s sexual functioning? A systematic review of the sexual consequences of FGM/C. Sex Res Social Policy 2012;9:41-56 8. Alsibiani SA, Rouzi AA. Sexual function in women with female genital mutilation. Fertil Steril2010;93:722-4
9. Vloeberghs E, van der Kwaal A, Knipscheer J, van den Muijsenbergh M. Coping and chronic psychosocial consequences of female genital mutilation in The Netherlands. Ethn Health 2012;17:677-95
10. ACOG 2020. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/01/elective-female-genitalcosmetic-surgery