Female genital mutilation: consequences, support and care

What do we mean by excision and female genital mutilation?

The World Health Organization (WHO) defines female genital mutilation (FGM) as any procedure involving partial or total removal of the external genital organs, or any other injury to these organs, carried out for non-medical reasons. The word "excision" is often used in everyday language to refer to all of these practices, but it actually corresponds to one specific type.

These procedures are most often carried out in childhood, sometimes in the first months of life, sometimes in adolescence or before marriage. Around 200 million girls and women worldwide live with genital mutilation, according to the figures cited by the HAS.

It is a violation of bodily integrity and an act of violence. A woman who has undergone it bears no responsibility for it.

What are the different types of mutilation?

The WHO classification, adopted by the HAS in 2020, distinguishes four types.

It is common for a woman not to know exactly which type of mutilation she has undergone, or even to be unaware that she has been cut. A gynaecological examination, carried out with her consent, allows this to be clarified calmly.

What are the health consequences?

The consequences vary according to the type of mutilation, the conditions in which it was carried out and each woman's experience. Some women report no discomfort; others have suffered for years without talking about it.

Physical and gynaecological consequences

• chronic vulval pain, sometimes related to a neuroma (a painful nerve scar) or a cyst;
• pain during intercourse (dyspareunia);
• burning or difficulty passing urine, urinary tract infections;
• painful periods, or periods that are difficult to pass in the case of infibulation.

A meta-analysis published in 2020 in PLoS Medicine, covering 116 studies, shows that women who have undergone FGM experience pain during intercourse about 2.5 times more often than women who have not been cut, and burning on urination about 1.4 times more often.

Obstetric consequences

The same meta-analysis found a roughly twofold higher risk of prolonged labour, episiotomy and perineal tears. These risks justify preparing for the birth and informing the obstetric team.

Psychological and sexual consequences

The HAS highlights how common post-traumatic stress, anxiety and depression are. Sexuality may be affected by pain, apprehension or reduced pleasure. These difficulties can be treated.

How does the consultation take place?

The HAS recommends that every primary care health professional should be able to identify mutilation, talk about it simply and refer the woman on. The consultation always begins with listening.

• The conversation: the woman is free to say what she wishes, at her own pace. The words used are chosen with her.
• The examination: it is only carried out with her explicit consent, and can be postponed. It allows the scar to be described and any cyst or painful area to be looked for.
• Understanding her expectations: relieving pain, understanding her body, preparing for a birth, improving her sex life, considering reconstruction, or simply being informed.
• A medical certificate can be written at the patient's request, particularly in the context of legal or protection proceedings.

How an examination takes place is explained in the article What happens at a gynaecologist appointment?

What care pathway is offered?

Care is multidisciplinary. Depending on needs, it involves:

Depending on each woman's needs, Dr Kadoch can refer her to appropriate professionals or a specialised care unit.

Possible surgical treatments

• Deinfibulation consists of opening the scar of an infibulation (type III). A systematic review published in the BJOG in 2018 (62 studies) associates deinfibulation with a lower risk of caesarean section and perineal tears. It can be carried out before or during pregnancy.
• Removal of a scar cyst is a simple procedure, with results considered favourable in studies.
• Clitoral reconstruction aims to reduce pain, improve sensation and restore self-image. It is described in detail in the article Clitoral reconstruction: procedure, recovery and results and on the page Clitoral reconstruction after excision.

The same BJOG review points out that data on reconstruction remain limited: after surgery, most women report an improvement in their sex life, but up to 22% report a worsening. Information about the expected benefits and the risks is essential.

Is care reimbursed?

The HAS specifies that clitoral repair is a reconstructive surgical procedure, not cosmetic surgery: it is covered by the Assurance maladie. Consultations, examinations and treatment of complications follow the usual reimbursement rules. Fee arrangements are explained during the consultation.

How can a girl or teenager be protected?

Excision is prohibited and punishable under French law, including when it is carried out abroad on a minor who habitually lives in France. The risks are greater during a trip to the family's country of origin.

The HAS recommends that health professionals make:

• in the event of imminent risk (planned departure, explicit family pressure): an immediate report to the public prosecutor (procureur de la République);
• in the event of non-imminent risk: a report of concern sent to the CRIP (cellule départementale de recueil des informations préoccupantes, the local child protection referral unit);
• in the event of mutilation observed in a minor: an immediate report to the public prosecutor.

These steps aim to protect the child. A woman who was cut as a minor can file a complaint up to 30 years after reaching the age of majority.

A mother under pressure to have her daughter cut can talk to the doctor, the midwife or the PMI (Protection maternelle et infantile, mother and child health service) doctor: they can help her protect her child and refer her to specialised associations.

When should you call for help?

• 119 (Allô enfance en danger, the French child protection helpline): for a threatened child or teenager, free, 24 hours a day.
• 3919 (Violences Femmes Info, the French helpline for women facing violence): for an adult woman, free and anonymous.
• 17 or 112: in the event of immediate danger; 114 by text message for deaf or hard-of-hearing people.
• 15: in the event of heavy bleeding, high fever or acute pain after a surgical procedure.

Frequently asked questions

General information article: it does not replace a medical consultation. In an emergency, call 15 or 112 in France, or your local emergency number.