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Systematic review

Gynecological consequences of female genital mutilation/cutting (FGM/C)

This systematic review aimed to summarize empirical quantitative research describing the gynecological consequences of FGM/C on girls and women.

This systematic review aimed to summarize empirical quantitative research describing the gynecological consequences of FGM/C on girls and women.


Key message

The traditional practice of female genital mutilation or cutting (FGM/C) covers a range of procedures (clitoridectomy, excision, infibulation, and other) performed on the genitals of females of different ages. This systematic review aimed to summarize empirical quantitative research describing the gynecological consequences of FGM/C on girls and women.

We included 136 primary studies, 42 of which compared groups of women who had been subjected to FGM/C with women who had no or different types of genital alterations. The main finding is that FGM/C has harmful consequences for a woman’s gynecological health. We found that:

  • Women with FGM/C seem to be more likely than women without FGM/C to experience urinary tract infection, bacterial vaginosis, and pain during intercourse.
  • There seems to be a trend for women with FGM/C to be more likely than women without FGM/C to experience: burning/painful urination, problems with menstruation, vaginal discharge and vaginal itching. 
  • There seems to be no clear trend for either a greater or lower risk of HIV and sexually transmitted infections among women who have undergone FGM/C.
  • There were insufficient data for us to conclude whether the risk of other gynecological complications (tissue damage, vaginal adhesions and obstructions, cysts, infertility) is different among women with FGM/C compared to women without FGM/C, and whether various FGM/C types differentially affect the risk of other gynecological complications (except regarding urinary tract infection).

This systematic review found that sufficient evidence exist to conclude that women who have undergone FGM/C suffer a greater risk of gynecological complications than women who have not undergone the procedure. There were no indications of gynecological benefits of FGM/C. Rather, there is a real chance of under-reporting of many of the health issues covered in this systematic review.

Summary

Background

The traditional practice of female genital mutilation or cutting (FGM/C) covers a range of procedures performed on the genitals of females of different ages. It is defined by the World Health Organization (WHO) as “all procedures involving partial or total removal of the female external genitalia or other injury to the female genital organs for non-medical reasons.”  According to the WHO typology, there are three main types of FGM/C: type I (clitoridectomy), type II (excision), type III (infibulation or pharaonic circumcision), and type IV which is used to describe all other harmful procedures to the female genitalia for non-medical purposes. According to a recent UNICEF report, there are over 125 million girls and women alive today who have undergone FGM/C in the 29 countries where the practice is concentrated. These are a swathe of 27 African countries stretching from the Atlantic Coast to the Horn of Africa, and Iraq and Yemen in the Middle East. In most countries for which reliable data are available, clitoridectomy and excision are most commonly practiced. Since FGM/C involves the cutting, or other alteration, of sensitive genital tissue, it is reasonable to assume that it is an act that is prejudicial to girls’ and women’s health in the short-term and long-term. Thus, the question addressed in the present systematic review is whether women who have been subjected to FGM/C are more likely than women who have not been subjected to FGM/C to experience long-term gynecological health complications.

Objective

This systematic review summarizes empirical quantitative research describing the gynecological consequences of FGM/C on girls and women (excluding obstetric consequences and sexual functioning, which are covered in separate reports). The overall aim of this systematic review is to support well-informed decisions in health promotion and health care that improve quality of services related to the consequences of FGM/C. The key research question was: What are the gynecological consequences of FGM/C?

Method

This systematic review was conducted in accordance with the guidelines in the NOKC Handbook for Summarizing Evidence and the Cochrane Handbook for Systematic Reviews of Interventions. The main literature search strategy was systematic searches for literature in 15 international electronic literature databases. Studies eligible for inclusion were systematic reviews, cohort studies, case-control studies, cross-sectional studies, case series, and case reports. The population of interest was girls and women who have been subjected to any type of FGM/C. In this report, we summarized the gynecological consequences of FGM/C, including outcomes such as infections, infertility, and problems with urination. We also included psychological health outcomes of FGM/C on girls (15 years or younger). Two reviewers screened literature, considered the methodological quality of the studies, and extracted data. Because results from studies with a comparison group are most valid for evaluating risk of experiencing complications, we prioritized presenting results from comparative studies. We summarized the study level results in texts and tables and calculated effect estimates. When an outcome was sufficiently similar across studies, we pooled those that could be grouped together using the statistical technique of meta-analysis. We applied the instrument Grading of Recommendations Assessment, Development and Evaluation (GRADE) to assess the extent to which we have confidence in the effect estimates.

Results

We included 136 primary (observational) studies reporting on gynecological outcomes among girls and women who had undergone FGM/C. There were 42 comparative studies (i.e., they compared groups of women with FGM/C to women with no- or a different type of genital alteration), including three case-control studies and one retrospective cohort study. We arrived upon a final decision of high methodological study quality for 19% of the comparative studies while 45% had moderate study quality. In our assessment, using the GRADE instrument, the quality of the evidence was very low with regards to documenting a conclusive relationship between FGM/C and gynecological consequences.

In total, the 136 studies included 130,558 women. The most frequently measured outcomes were cysts, various vaginal obstructions, and tissue damage. However, many of the sequels were relatively rare events. Therefore, there were often few events that could be entered into analyses, which in turn meant that the analyses were often unable to establish whether there are statistically significant differences between groups being compared. Consequently, there was in many cases insufficient information available from the included studies to inform the question of difference in risk. There was only one study concerning psychological health outcomes among girls. The main finding is that FGM/C has harmful consequences for a woman’s gynecological health. We found that:

  • Women with FGM/C seem to be more likely than women without FGM/C to experience urinary tract infection, bacterial vaginosis, and pain during intercourse.
  • There seems to be a trend for women with FGM/C to be more likely than women without FGM/C to experience: burning/painful urination, problems with menstruation, vaginal discharge and vaginal itching. 
  • There seems to be no clear trend for either a greater or lower risk of HIV and sexually transmitted infections among women who have undergone FGM/C.
  • There were insufficient data for us to conclude whether the risk of other gynecological complications (tissue damage, vaginal adhesions and obstructions, cysts, infertility) is different among women with FGM/C compared to women without FGM/C, and whether various FGM/C types differentially affect the risk of other gynecological complications (except regarding urinary tract infection).

Discussion

The findings show that women who have been subjected to FGM/C seem to be at greater risk for urinary tract infections and bacterial vaginosis, and possibly also at greater risk for pain during intercourse, burning/painful urination, problems with menstruation, and vaginal discharge and itching when compared to women who have not been subjected to FGM/C. Whatever the mechanisms for the higher prevalences of these gynecological problems and symptoms among women who have undergone FGM/C are – even years and decades after the procedure – these results thus strengthen arguments that FGM/C is injurious for women’s health. There is a real chance of under-reporting of many of the health issues covered in this systematic review, due to women’s reluctance to report complications in contexts where FGM/C is discouraged, or even illegal, and failure to attribute the complication to FGM/C. Some studies had few participants and/or a low number of events, which decreased studies’ power to detect potential differences and produced wide confidence intervals, which in turn lowered the quality of the evidence. However, from a women’s health perspective, irrespective of the range of complications or exact size of the greater risk from FGM/C, even the lowest rates of complications are undesirable. We believe sufficient evidence exist to conclude that women who have undergone FGM/C suffer a greater risk of physical complications, thus, future research should attend to appropriate care and treatment for girls and women who suffer complications.

Conclusion

This systematic review found that sufficient evidence exist to conclude that women who have undergone FGM/C suffer a greater risk of gynecological complications than women who have not undergone the procedure. There were no indications of gynecological benefits of FGM/C.

    About this publication

  • Year: 2014
  • Authors Berg Rigmor C, Underland Vigdis.
  • ISSN (digital): 1890-1298
  • ISBN (digital): 978-82-8121-864-2