The World Health Organization (1997) defined Female Genital Mutilation (FGM) as "all procedures involving partial or total removal of the female external genitalia or other injury to the female genital organs whether for cultural or other non-therapeutic reasons".
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The United Nations identifies FGM as a form of human rights abuse on the female child and supports the eradication of this practice in countries where it is practiced.
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1. Background information
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1.1 Origins of practice
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The act of Female Genital Mutilation predates both Christianity and Islam and does not pertain to any specific religion. The practice of infibulation is thought to have arisen out of ancient Egypt. It is also suggested that FGM was associated with patriarchal societies in which men needed assurance of family blood lines. Clitoridectomy, a less extreme form of FGM, was known to be used in Western medicine as late as the 1950s as a treatment for perceived 'female psychiatric illnesses'.
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1.2 Reasons for the practice
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These are complex, arising from a belief system based on cultural and social tradition and impinge on the woman's social acceptance and marriageability within her community. While some people believe FGM to be part of religious requirements, this is in fact not the case.
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1.3 Prevalence of practice
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The WHO (2000) estimates that as many as 100 and 140 million women and girls are affected world wide. This extrapolates to approximately 3 million girls per year at risk of being circumcised. Regions where various extremes of FGM are practiced include Africa, Asia, South America and the Middle East.
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1.4 Use of terminology
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The term Female Genital Mutilation may cause offence to some who practice or have experienced the procedure. Its use in consultation may have the potential to be counterproductive to forming an effective professional relationship with the client and hence detrimental to the provision of her ongoing care for what is a sensitive issue. Accepted forms of description are traditional female surgery or cutting or female circumcision.
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1.5 Legal issues
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Staff are expected to be aware of specific legislation in the State of Victoria and elsewhere in Australia which makes it a criminal offence to perform FGM and/or remove a child from the country to have FGM.
Further information is available from the FARREP Manager, FARREP workers and the Royal Women's Hospital legal Counsel.
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1.6 Referrals
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Referrals to appropriate healthcare providers should be offered to women, including referral to a FARREP worker.
The Women's offers the de-infibulation procedure to both pregnant and non-pregnant women.
Contact may be made via FARREP or WHIC.
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1.7 Support and resources for staff
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Support/advice can be gained from:
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- the Women's Family and Reproductive Rights program (FARREP) Tel: (03) 8345 3058, the FARREP Manager Tel: (03) 8345 3071 or
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- FGM Liaison Officers - access information as required from: FGM Liaison Officers: Medical, Nursing/Midwifery and Allied Health Staff (Policy and Procedure Manual - intranet only).
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2. Types of Female Genital Mutilation
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The different types of FGM are classified by the extent of the surgery:
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| Excision of the prepuce, with or without excision of part or all of the clitoris.
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| | Excision of the clitoris with part or total excision of the labia minora
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| | Excision of part or all of the external genitalia and stitching / narrowing of the vaginal opening (infundibulation)
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| | Unclassified, but includes: pricking, piercing or incising the clitoris and/ or labia, stretching of the clitoris and/ or labia, cauterization by burning of the clitoris and surrounding tissue, scraping of the tissue surrounding the vaginal orifice or cutting of the vagina, the introduction of corrosive substances or herbs into the vagina to initiate tightening, bleeding or narrowing of the vagina, as well as any other procedure which falls under the WHO definition of FGM.
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3. Health consequences of Female Genital Mutilation
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There are a number of health problems associated with FGM (listed below).
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3.1 Short term health issues:
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- damage to adjacent tissues
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- death can result from infection or haemorrhage
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3.2 Long term health issues:
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- recurrent UTIs and vaginal infections
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- surgical reversal of scar tissue in order to achieve intercourse.
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FGM may have long term effects on the psychosexual and psychological health of those who have undergone the procedure.
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In more recent times concern has been expressed about the possible transmission of human immunodeficiency virus (HIV) due to the use of one instrument for multiple FGM procedures, but as yet is not confirmed by research (WHO, 2000).
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4. Management
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Women from regions known to practice the procedure should be asked whether they have undergone female circumcision in their first antenatal appointment at the hospital.
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Staff should be aware that women affected by the practice may also be experiencing a range of psychosocial issues that have arisen from their experience of FGM and/or migration and resettlement.
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The aim needs to be holistic care that is culturally sensitive and non judgemental (RANZCOG, 1997).
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The gender provider wishes of the woman should be taken into account in regard to care and referral.
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Refer to the Women's Health Professional section of their public website: Female Genital Mutilation / Cutting.
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If the woman has been affected by FGM, an appointment should be made for her to see a FGM Liaison Medical Officer, who will discuss with the woman her options regarding de-infibulation during pregnancy or labour (refer to flowcharts under Appendices) or she can be referred to the Well Women’s de-infibulation clinic. A list to of FGM Liaison Officers follows (refer to Policy and Procedure Manual, intranet only): FGM Liaison Officers: Medical, Nursing/Midwifery and Allied Health Staff.
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4.1 Clinical management
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For details including de-infibulation and re-suturing diagrams and instructions, refer to the FGM Clinical Management Guidelines (separate page).
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4.2 De-infibulation - gynaecology
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A process has been established to enable women to access two options for de-infibulation: under local anaesthetic or general anaesthetic (refer to FGM Flowchart: De-infibulation Service Pathway under Appendices in this CPG).
A woman should be booked via the Women’s Health Information Centre (WHIC) in to the Well Women’s de-infibulation clinic where an assessment regarding suitability for local or general anaesthetic will be conducted.
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4.3 De-infibulation during pregnancy and labour
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De-infibulation is a form of corrective surgery.
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The available options should be discussed with the woman early in the pregnancy to facilitate appropriate management.
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If de-infibulation is requested by a pregnant woman, the procedure is best performed in the antenatal period between 20 and 34 weeks gestation, to facilitate clinical care during pregnancy and labour.
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There are three options available for women and all options should be discussed by an FGM Obstetric Medical Officer with the women so she can make an informed choice (refer to Antenatal flowchart):
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| De-infibulation under local anaesthetic in the Well Women’s De-infibulation clinic. Appointments can be made by contacting WHIC.
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| | De-infibulation under general anaesthetic conducted by a FGM Gynaecologist Medical Officer. A FGM Obsteric Medical Officer can book a woman onto an FGM Gynaecologist Medical Officer’s surgery list.
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| | A woman may choose to be de-infibulated during labour as part of the birth process.
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The woman needs to decide what is the best option for her with her health professional.
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4.4 Suturing post de-infibulation
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Guidelines for suturing post de-infibulation:
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- following de-infibulation, over-sewing of the raw margins of the anterior incision is required to prevent re-infibulation with potentially poor approximation of wound edges.
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- any extension of the anterior incision above the urethra may be repaired at that time.
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- a routine repair of a medio-lateral episiotomy or perineal tear is also frequently required post labour.
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5. Appendices
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5.1 Flowcharts
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| FGM: De-infibulation Service: Pathway
| Select thumbnail to view full size image of FGM: De-infibulation Service: Pathway (pdf 30kb)
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| FGM Flowchart: Antenatal
| Select thumbnail to view full size image of FGM: Flowchart: Antenatal (pdf 31kb)
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| FGM Flowchart: Birth Centre
| Select thumbnail to view full size image of FGM Flowchart: Birth Centre (pdf 25kb)
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| FGM Flowchart: Postnatal
| Select thumbnail to view full size image of FGM Flowchart: Postnatal (pdf 23kb)
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5.2 Additional information for health professionals
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Additional information for health professionals can be located on the following page:
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- Female Genital Mutilation / Cutting contains the following information:
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 | - FGM Fact Sheet for Health Professionals
- FGM Fact Sheet: What does Victorian law say about Female Genital Mutilation?
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6. References
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6.1 The Women's information
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6.2 References
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Please note that the contents of this CPG are duplicated in the CPG: Female Genital Mutilation - Women's Health.
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Revised and updated:
1 October 2010
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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