Surgical management of female genital mutilation-related morbidity: A scoping review

Examining the key features of specialist health service provision for women with Female Genital Mutilation/Cutting (FGM/C) in the Global North: a scoping review

Background

Health care for women with Female Genital Mutilation/Cutting (FGM/C) in the Global North is often described as sub-optimal and focused on maternity care. Specialist FGM/C services have emerged with little empirical evidence informing service provision. The objective of this scoping review is to identify the key features of FGM/C specialist care.

Methods

The review was conducted in accordance with JBI methodology. Participants: organisations that provide specialist FGM/C care. Concept: components of specialist services. Context: high-income OECD countries. Eligibility criteria included primary research studies of any design from 2012 to 2022, providing a comprehensive description of specialist services. Seven bibliographic databases were searched (MEDLINE, EMBASE, CINAHL, Web of Science, SCOPUS, Cochrane Library and MIC). The components of "specialist" (as opposed to "generalist") services were defined and then applied to an analysis of FGM/C specialist care. FGM/C specialist provision was categorised into primary (essential) and secondary features. Data were extracted and analysed descriptively through charting in tables and narrative summary.

Results

Twenty-five papers described 20 unique specialist services across eleven high income countries. Primary features used to identify FGM/C specialist care were:-(i) Named as a Specialist service/clinic: 11/20 (55%); (ii) Identified expert lead: 13/20, (65%), either Midwives, Gynaecologists, Urologist, or Plastic Surgeons; (iii) Offering Specialist Interventions: surgical (i.e., reconstruction and/or deinfibulation) and/or psychological (i.e., trauma and/or sexual counselling); and (iv) Providing multidisciplinary care: 14/20 (70%). Eleven services (in Spain, Sweden, Switzerland, Germany, Italy, Netherlands, France, Belgium, and USA) provided reconstruction surgery, often integrated with psychosexual support. No services in UK, Norway, and Australia offered this. Six services (30%) provided trauma therapy only; 25% sexual and trauma therapy; 15% sexual therapy only; 30% did not provide counselling. Secondary features of specialist care were subdivided into (a) context of care and (b) the content of care. The context related to concepts such as provision of interpreters, cost of care, community engagement and whether theoretical underpinnings were described. Content referred to the model of care, whether safeguarding assessments were undertaken, and health education/information is provided.

Conclusion

Overall, the features and composition of FGM/C specialist services varied considerably between, and sometimes within, countries. Global guidelines advocate that specialist care should include access to deinfibulation, mental health support, sexual counselling, and education and information. The review found that these were rarely all available. In some high-income countries women cannot access reconstruction surgery and notably, few services for non-pregnant women mentioned safeguarding. Furthermore, services for pregnant women rarely integrated trauma therapy or psychosexual support. The review highlights a need for counselling (both trauma and psychosexual) and culturally-appropriate sensitive safeguarding assessments to be embedded into care provision for non-pregnant as well as pregnant women. Further research is needed to extract the features of specialist services into a comprehensive framework which can be used to examine, compare, and evaluate FGM/C clinical specialist care to determine which clinical features deliver the best outcomes. Currently a geographical lottery appears to exist, not only within the UK, but also across the Global North.

Effect of type III female genital mutilation on obstetric outcomes: A systematic review and meta-analysis

Background

Controversial evidence suggests a potential association between female genital mutilation (FGM/C) and adverse obstetric outcomes, with type III FGM/C (infibulation) carrying the greatest risk. The aim of this systematic review and meta-analysis was to assess current rate of adverse obstetric outcomes in women with type III female genital mutilation and cutting (FGM/C; infibulation) delivering across different settings worldwide.

Methods

We searched PubMed, Scopus, Embase, and ClinicalTrials.gov databases from inception to Jan 1, 2023. Studies were selected if they included the main outcome of postpartum haemorrhage (PPH) or secondary outcomes, which included major conditions affecting maternal-neonatal health during labour and delivery. DerSimonian-Laird random effects meta-analysis including pooled effect estimates with corresponding 95 % confidence intervals was performed. Heterogeneity was assessed using the I2 statistic. Meta regression for relevant covariates was performed when data on relevant confounders were available. The Newcastle-Ottawa scale (NOS) was used to assess quality of observational studies. The level of evidence was assessed with the GRADE method.

Results

14 observational studies including 15,320 type III FGM/C women and 59,347 controls were eligible. The risk for postpartum haemorrhage was significantly increased in type III FGM/C, in the main analysis (OR 1.83, 95 % CI 1.03 to 3.24, I2 = 93 %), in pooling of data adjusted for confounders (aOR 1.76, CI 1.42 to 2.17, I2 = 0 %), and in sensitivity analysis of higher quality studies with NOS≥7 (OR 2.76, CI 1.38 to 5.51, I2 = 95 %). Meta-regression showed that nulliparity was significantly and positively associated with postpartum haemorrhage. Similarly, analysis of data adjusted for confounders showed an increased risk of episiotomy in type III FGM/C (aOR 1.56, CI 1.03 to 2.35, I2 = 52 %). Sensitivity analysis of studies with NOS≥7 revealed a significant increase for episiotomy (OR 7.53, CI 1.19 to 47.54, I2 = 96 %), perineal tears (OR 4.24, CI 1.09 to 16.46, I2 = 66 %), prolonged second stage of labour (OR 5.19, 95 % CI 1.00 to 26.85, I2 = 66 %), and Apgar score less than 7 (OR 4.19, CI 1.64 to 10.70, I2 = 0 %). No difference was found regarding obstetric anal sphincter injuries and mode of delivery in these women. Deinfibulation achieved similar obstetric and neonatal outcomes to women who never had type III FGM. The overall quality of the studies was adequate (median NOS score: 7; IQR: 6-8), the level of evidence, according to the GRADE assessment, was low.

Conclusions

These results consistently show an increased risk of adverse obstetric outcomes in women with FGM/C type III. Infibulation substantially increases the risk for PPH, particularly in nulliparae. Systematic Review registration: PROSPERO CRD42023421993.

Postoperative Course of Reconstructive Procedures in FGM Type III-Proposal for a Modified Classification of Type III Female Genital Mutilation

BACKGROUND

Reconstruction after female genital mutilation (FGM) has developed from being merely a therapy for complications to addressing body perception and sexuality. However, evidence regarding a direct correlation between FGM and sexual dysfunction is scarce. The present WHO classification provides an imprecise grading system, which makes it difficult to compare present studies with treatment outcomes. The aim of this study was to develop a new grading system based on a retrospective study of Type III FGM, evaluating operative time and postoperative results.

METHODS

The extent of clitoral involvement, operative time of prepuce reconstruction and lack of prepuce reconstruction, and postoperative complications of 85 patients with FGM-Type III were retrospectively analyzed at the Desert Flower Center (Waldfriede Hospital, Berlin).

RESULTS

Even though universally graded by the WHO, large differences in the degree of damage were found after deinfibulation. In only 42% of patients, a partly resected clitoral glans was found after deinfibulation. There was no significant difference in operative time when comparing patients who required prepuce reconstruction and patients who did not (p = 0.1693). However, we found significantly longer operative time in patients who presented with a completely or partly resected clitoral glans when compared to patients with an intact clitoral glans underneath the infibulating scar (p < 0.0001). Two of the 34 patients (5.9%) who had a partly resected clitoris required revision surgery, while none of the patients in whom an intact clitoris was discovered under the infibulation required revision. However, these differences in the complication rates between patients with and without a partly resected clitoris were not statistically significant (p = 0.1571).

CONCLUSIONS

A significantly longer operative time was found in patients who presented with a completely or partly resected clitoral glans when compared with patients with an intact clitoral glans underneath the infibulating scar. Furthermore, we found a higher, though not significantly significant, complication rate in patients with a mutilated clitoral glans. In contrast to Type I and II mutilations, the presence of an intact or mutilated clitoral glans underneath the infibulation scar is not addressed in the present WHO classification. We have developed a more precise classification, which may serve as a useful tool when conducting and comparing research studies.

[175 years of anesthesia and narcosis-Towards a "human right to unconsciousness"]

The Ether Day, a key moment in the history of mankind, commemorates its 175th anniversary on 16 October 2021. On that day the dentist William T. G. Morton successfully gave the first public ether anesthesia in Boston. From then on it was possible to save people from pain with justifiable risk and at the same time to protect them from psychological damage by inducing unconsciousness. The German philosopher Peter Sloterdijk, one of the most renowned and effective philosophers of our times, deduced that from then on humans, to some extent, had a right to unconsciousness when in psychophysical distress. This postulate unfolded from his concept of "anthropotechnics" developed around 1997, meaning the idea of treating human nature as an object of possible improvements. According to Sloterdijk, in favorable cases a synthesis of man and technology can result in a significant improvement of human capabilities in the sense of "enhancement", i.e. an increase, an improvement or even an expansion of intellectual, physical or psychological possibilities, as it were in a transgression of the human (so-called transhumanism). Man should go into vertical tension, i.e. strive for higher aims and exploit his inherent potential, he should not dwell in the horizontal. This is not meant as an appeal but as an imperative: "You must change your life!". In this context modern anesthesia may prove helpful: be operated on by others in order to undergo an enhancement. Or, in its most extreme form, the operation in the "auto-operational curved space", a person can even operate on himself as has been dramatically demonstrated by Rogozov, a young Russian physician and trainee surgeon who successfully performed a self-appendectomy under local anesthesia at the Novolazarevskaya Antarctic Station in 1961; however, the implementation of this idea is a long way off. On the one hand, many countries lack qualified personnel in sufficiently large numbers to perform even vital operations with patients under anesthesia. On the other hand, over the decades it has become clear that anesthesia is obviously beneficial for mankind in that it offers relief from pain and psychological stress but that it can also often show its dark side: substance abuse, use of anesthetics in torture and in executions. In addition, the role of anesthetics in resuscitation, palliative care, and allaying executions is unclear or controversial. Finally, the necessary formal legal steps to acknowledge a "human right to unconsciousness" have not yet been implemented.