Title: Female genital mutilation Content: Female genital mutilation (FGM) is cutting off part or all of the female genitals that are outside of the body. FGM is also called female genital cutting and female circumcision. It is done for traditional reasons, as part of a ritual, not for medical reasons. FGM is most common in 27 African countries, as well as Yemen and Iraqi Kurdistan. However, it also happens in other countries in Asia, the Middle East and around the world.UNICEF 2013 , pp. 2, 26-27 Usually, FGM is not done by a doctor or in a hospital.UNICEF 2013 , pp. 2, 44–46 It is often done with a razor blade or other sharp instruments, in many cases without anesthesia. Different ethnic groups do different kinds of FGM. They also do FGM at different ages. Some groups do FGM when infants are only a few days old. Others do it when girls reach puberty, or are older. In about half the countries where FGM happens, most girls have FGM before they are five years old. FGM can cause serious health problems, like infections, chronic pain, trouble getting pregnant and giving birth, bleeding so bad that it can kill.Jasmine Abdulcadira, et al, "Care of women with female genital mutilation/cutting" , Swiss Medical Weekly, 6(14), January 2011. PMID 21213149 FGM does not make a person's health better in any way."Female genital mutilation", New York: World Health Organization, February 2014. FGM is illegal in most of the countries where it happens.UNICEF 2013 , p. 8 However, these laws are often ignored.UNFPA–UNICEF 2012, p. 48. Since the 1970s, many countries have tried to stop FGM. In 2012, the United Nations General Assembly said that FGM is a human rights problem, and voted to try harder to stop it."67/146. Intensifying global efforts for the elimination of female genital mutilation", United Nations General Assembly, adopted 20 December 2012. The World Health Organization and the "Maputo Protocol" to the African Charter on Human and Peoples' Rights also say that FGM must be stopped. ==Types of female genital mutilation== There are many different types of female genital mutilation. The World Health Organization (WHO) has created four basic categories of FGM, called Types 1-IV.WHO 2014; WHO 2008 ===Type I=== In Type I FGM, part or all of the clitoris is cut off. The clitoris is the female organ that makes sex feel good for women. Without it, a woman usually cannot have an orgasm. right|300px|alt=Diagram showing types of female genital mutilation| ===Type II=== There are a few forms of Type II FGM. All of them involve cutting off part or all of the inner labia, the two flaps of skin on the sides of the opening to the vagina. The forms of Type II FGM are:WHO 2014. * Type IIa: The inner labia are cut off. * Type IIb: The inner labia and part of the clitoris are cut off. * Type IIc: The inner labia and part of the clitoris are cut off. So is the outer labia, the folds of skin that protect the genitals. ===Type III=== Type III FGM is usually called infibulation. It is the most severe form of FGM. The genitals outside a woman's body are cut off and the wound is sewn shut with thread and thorns.Kelly and Hillard 2005, p. 491 The different types of infibulation are: * Type IIIa: The inner labia are cut off and sewn closed. * Type IIIb: The outer labia are cut away and sewn closed. When the labia are sewn shut, one small hole is left open so the girl can urinate and menstruate. The hole is kept open by putting something like a twig into the wound.Abdulcadira et al. 2011 . To help the wound close, the girl's legs are tied together, often from hip to ankle, for up to six weeks.Ismail 2009 , p. 14. After the woman gets married, her vagina is cut open so she can have sex. A midwife might cut open the vagina with a knife, or the woman's husband might tear it open with his penis.Abdalla 2007, pp. 191, 198 If the woman gets pregnant, the vagina is opened more for childbirth, and then often sewn back up afterward (this is called re-infibulation).Kelly and Hillard 2005, p. 491. ===Type IV=== Type IV FGM is anything else that is done to hurt the genitals, like scraping, burning, scarring, or cutting the genitals without cutting them off. This procedure will be heartbreaking for women, when they get to know about this in later life.WHO 2008, p. 24; UNICEF 2013 , p. 7. == Prevalence == In many countries where FGM is common, almost every woman and girl in the country has had FGM. In other countries, millions of women and girls have had FGM over many years. In 25 countries in Africa and the Middle East, over 125 million women and girls have had FGM. This includes: * 27.2 million girls and women in Egypt * 23.8 million in Ethiopia * 19.9 milllion in Nigeria * 12.1 million in Sudan * 9.3 million in Kenya and Burkina Faso; and * Millions of other girls and women in other countries. In some of these same 25 countries, FGM is very common. It is most common in these countries: * Somalia: 98% of girls and women in the country have had FGM * Guinea: 96% * Djibouti: 93% * Egypt: 91% * Eritrea: 89% * Mali: 89% * Sierra Leone: 88% * Sudan: 88% However, in other countries, FGM is not as common. For example, of the 25 countries where FGM happens most often, it is least common in these countries: * Uganda: 1% of girls and women in the country have had FGM * Cameroon: 1% * Niger: 2% * Togo: 4% * Ghana: 4% * Iraq: 8% ==Complications== FGM can hurt women's physical and mental health throughout their lives.Rigmor C. Berg, et al., "Effects of female genital cutting on physical health outcomes: a systematic review and meta-analysis", BMJ Open, 4(11), 2014: e006316. Dan Reisel, Sarah M. Creighton, "Long term health consequences of Female Genital Mutilation (FGM)", Maturitas, 80(1), January 2015 (pp. 48–51), p. 49\. The type of complications that a girl or woman might have from FGM depend on many things, like: * The type of FGM * Whether the FGM was done by someone with medical training * Whether antibiotic medicines were used * Whether sterile(clean and safe) tools were used ===Short-term complications=== "Short-term complications" are health problems caused by FGM soon after the FGM happened. Common short-term complications include:Rigmor C. Berg, Vigdis Underland, "Immediate health consequences of female genital mutilation/cutting (FGM/C)" , Kunnskapssenteret (Norwegian Knowledge Centre for the Health Services), systematic review no. 8, 2014, pp. 4–5 (full text ). * Swelling * Dangerous bleeding * Pain * Trouble urinating normally * Infection and trouble healing More serious short-term complications can cause symptoms that can kill a woman. They include:Christos Iavazzo, Thalia A. Sardi, Ioannis D. Gkegkes, "Female genital mutilation and infections: a systematic review of the clinical evidence", Archives of Gynecology and Obstetrics, 287(6), June 2013, pp. 1137–1149. * Sepsis * Tetanus * Gangrene * Necrotizing fasciitis ("flesh- eating disease") * Bleeding to death Nobody knows how many girls and women die from FGM.UNICEF 2005, p. 16.Reisel and Creighton 2015, p. 50. ===Late complications=== Late complications happen later on after FGM is done. For example:Kelly and Hillard 2005, pp. 491–492Amish J. Dave, Aisha Sethi, Aldo Morrone, "Female Genital Mutilation: What Every American Dermatologist Needs to Know", Dermatologic Clinics, 29(1), January 2011, pp. 103–109. Hamid Rushwan, "Female genital mutilation: A tragedy for women's reproductive health", African Journal of Urology, 19(3), September 2013, pp. 130–133. * Scars, which can block urine and blood from getting out of the body * Cysts, which can become infected * Damage to the bladder and urethra * Infibulated girls can have trouble or pain when urinating. They can also have infections and pain during sex. Painful periods are common because it is very difficult for the monthly menstrual blood to get out of the tiny hole left by infibulation. Blood can fill the vagina and uterus, and stay there without moving. If the vagina gets completely blocked, the vagina and uterus can fill up completely with menstrual blood. Because women with this problem do not menstruate, and blood builds up in their abdomen (making it swell), it can be confused with pregnancy. ===Pregnancy and childbirth=== FGM may increase a woman's risk of having problems during pregnancy and childbirth. For example, women who had infibulations are more likely to:Rashid and Rashid 2007, p. 97. * Have third-degree lacerations (very bad skin tears around the vagina) when they try to give birth * Have damage to their anal sphincters from giving birth, affecting bowel control; and * Need emergency caesarean sections FGM also raises the risk that a woman's baby will die soon after it is born. In 2008, the WHO estimated that 10–20 babies out of every 1,000 die because their mothers had FGM. All types of FGM were found to raise babies' risk of death, which was:Emily Banks, et al, "Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries", The Lancet, 367(9525), 3 June 2006, pp. 1835–1841. "New study shows female genital mutilation exposes women and babies to significant risk at childbirth", World Health Organization, 2 June 2006. * 15 percent higher for Type I FGM; * 32 percent higher for Type II; and * 55 percent for Type III. ===Effects on mental health & sexual function=== There is not much information about the effects of FGM on women's and girls' mental health. However, a few small studies have found that women with FGM often have anxiety, depression, and post-traumatic stress disorder (PTSD). Studies on how FGM affects women's ability to have sex have also been small. In total, in 2013, there had been 15 studies involving 12,671 women from seven countries. When all the information from these studies was put together, researchers found that:Rigmor C. Berg, Eva Denison, "A Tradition in Transition: Factors Perpetuating and Hindering the Continuance of Female Genital Mutilation/Cutting (FGM/C) Summarized in a Systematic Review", Health Care for Women International, 34(10), March 2013. * Women with FGM were twice as likely than other women to say they never felt like having sex * Women with FGM were 52% more likely than other women to have dyspareunia (pain during sex) * One-third of women with FGM had less sexual feelings than before their FGM.