THE RISK OF MEDICAL COMPLICATIONS AFTER FEMALE CIRCUMCISION
M. A. DIRIE and G. LINDMARK
The medical complications of the practice of circumcision were studied in 290 Somali women between the ages of 18-54. Thirty-nine percent of the interviewed women had experienced significant complications after circumcision, most commonly hemorrhage, infection or urinary retention. Thirty-seven of the women reported a late complication of circumcision. Among these complications were dermoid cyst at the site of the amputated clitoris, urinary problems such as pain at micturition, dribbling urine incontinence and poor urinary flow. Forty of the women had experienced problems at the time of menarche and ten of them were operated because of haematocolpos. Most of married women of the study sample were defibilated naturally by their husbands.
It is not known when the practice of female circumcision first appeared, but some authors believe that it began during the pharaonic era of Egypt(1). Female circumcision was first discovered in ancient Egyptian mummies in 200 B.C.(2). In the pre-islamic era the custom was widespread in Egypt, Arabia and along the coast of the Red Sea. Nowadays it is practised in many African countries(3). Female circumcision is performed in three different ways:
The Sunna type is analogous with male circumcision and consists of the excision of the prepuce of the clitoris.
The clitoridectomy type consists of the excision of the clitoris sometimes with parts of the minor labia.
The excision and infibulation operation means excision of the whole clitoris, the minor labia and the internal faces of the major labia. The remains of the major labia are then stitched together and a small opening left at the lowermost part of the vulva. Sometimes this opening is measured by a piece of wood which is about the thickness of a match stick. Urine and menstrual blood dribble through that opening and this entails serious consequences to the gynaecological health of the woman. Immediate medical complications are frequent and often serious. They are haemorrhagic, infection and urinary retention.
In this paper the risk of medical complications are studied and reported by a group of women in Mogadishu, Somalia.
MATERIALS AND METHODS
Three hundred women of the population of Mogadishu, the capital of Somalia, were selected for the study. Ten of the recruited women were later excluded because they did not answer all of the questions properly. A questionnaire was developed for the purpose. The questionnnaire was designed to obtain information concerning the age at circumcision, type of circumcision, the person performing the operation, the reasons given for the practice, medical complications endured and the attitudes to the practice in the future. The questionnaire was constructed with preformulated answers but the women also added their own comments. In the enquiry of the medical complications, sexual and obstetrical complications were intentionally excluded. The questionnaire was administered by a medical student to each respondent separately and filled in at an interview. This took an average half an hour depending on the education and collaboractiveness of the respondent.
The mean age of the respondents was 22 years (range 18-54). The social characteristics of the women are described in a previous paper. Eighty-eight percent of the repondents were circumcised with excision and infibulation, while the remaining were circumcised with clitoridectomy (6.5%) and Sunna (5.5%). Sixty-nine percent of the respondents were circumcised at home and 52% of them were circumcised by an untrained person, mostly a traditional birth attendant (TBA)(4).
The medical complications endured by the women are both immediate and late. Immediate complications are defined as complications directly following the operation. Late complications are those appearing after the primary healing of the circumcision.
It was not difficult for most of the respondents to recall the suffering from the complications of female circumcision. Some gave detailed descriptions of the circumstances surrounding the act of circumcision and the immediate complications they experienced. However, a few of the respondents felt shy and were not able to speak of their genital organs. Therefore they probably underreported the complications that they had endured. This was especially relevant to the late complications, which included the symptoms the women were suffering from at the time of the interview. It was for instance difficult for them to admit, in the presence of strangers, that they were suffering of dribbling urine incontinence which is a common complication of infibulation.
The immediate main complication as reported by 112 women were haemorrhage, local infection, urinary retention and septicaemia (Table 1). The experienced haemorrhage was often significant. Five of the women reported getting into shock and two of them only recovered after being treated in hospital with blood transfusion. The cases with urinary retention were treated by splitting up the infibulation scar which relieved their sufferings. They were however reinfibulated a couple of weeks later. The cases with local infection from the circumcision did not get any medical treatment but some of them healed with the destruction of the infibulation. Also these cases were reinfibulated a few months later.
One hundred and eight women of the sample studied experienced late complications of female circumcision such as pain at micturition, clitoral cyst and poor urinary flow (Table 2). The pain at micturition was recurrent, sometimes disappearing and appearing again. Most likely the pain was due to recurrent urinary infection. The women consulted physicians for these complaints and antibiotics were prescribed for them. This sometimes brought relief of the symptoms. Two women developed urethral stricture and were operated on. Thirty-six subjects complained of a cyst appearing at the site of the amputated clitoris and 29 had the cyst excised. Five of the subjects reported anxiety about the nature of the cyst and thought it might develop into a masculine organ such as a penis. Fifteen women reported poor urinary flow due to tight infibulation. All of them consulted a physician but no one accepted to be defibulated in order to get remedy to the problem.
One hundred fifteen of the women studied had reached fertile age at the time of the survey. Forty (14%) of these women had experienced difficulty at the onset of menarche with painful menstruations or haematocolpos, and twenty-nine of them consulted a physician. Ten of those reported that they were surgically defibulated and the haematocolpos was evacuated.
As shown in Figure 1, there were one hundred and nineteen married and defibulated women among the study sample. Defibulation means splitting up the bridge of skin that covers the vulva after infibulation. Ninety-two (87%) of those women were defibulated by their husbands without the need of instruments. The remaining twenty-seven (23%) were defibulated with the use of various instruments such as knives, razor blades and scissors. Seventeen of these were operated on by their husbands and the remaining 10 by other women, as a rule close relative of their husbands. Two women reported that they rejected the idea of another person defibulating them when their husbands suggested it. They said that they would not endure the shame that this would entail, when it became known to al that their husbands were incapable of defibulating them without help.
The haemorrhage complicating circumcision often occurs because the operation is performed by untrained persons, who do not know how to achieve adequate haemostasis. The cut vessels are not ligated and no suturing done. The legs of the young girls are straightened and tied together to give haemostasis. This often fails, as reported by women in the study. If the operation is not being performed under aseptic conditions, it can result in local infection. Tetanus infection is not uncommon. But like other lethal complications is not possible to find in a retrospective study.
The urinary retention by women studied is common during the first three days after the operation because the girl tries to avoid the pain when the urine irritates the newly operated raw parts of the external genitals. Skin flaps or blood clots can also be the cause of the urinary retention. In several cases the urethra can be included in the sutures while closing the vulva(5). Similar results have also been found in the study in the Sudan, when it comes to type and frequency of immediate complications of female circumcision(6). The local infection of the wound at the time of circumcision, later on at defibulation at the time of marriage and at delivery can cause difficult health problems for these circumcised women. The spread of the infection to the inner reproductive organs can cause infertility problems(5,7).
Urinary problems were most common as late complications. Recurrent urinary infections with pain at micturition occur because the meatus of the urethra is covered by the infibulation resulting in a cumulation of vaginal discharge which is favorable environment for bacterial growth. Micturition is also difficult as reported by the women. Lesions inflicted on the girls at the time of circumcision with damage to the urethra or episodes of urethritis may cause urethral strictures resulting in poor urinary flow, and pain at micturition. The female patients with post circumcision complications treated during an 8-year-period at a university hosptial in Nigeria presented in 28% with urinary problems caused by complete labial fusion, meatal obstruction, urethral stricture and urinary infection(8).
Cyst development at the site of the excised clitoris is widely reported and is most likely caused by the invagination of islands of epithelial tissues at the time of infibulation(5,6,9,10) These grow into a cyst which usually develops slowly but can reach considerable size.
The problems of female circumcision at menarch are significant as reported by women in the survey and in other studies(9). Three and half percent of the women studied, reported haematocolpos and were operated on. The frequency in Sudan is 2%(2). This particular ailment must be very common in Somalia, Sudan and other areas where infibulation is prevalent.
Defibulation, of course, must be as common as circumcision in a community where infibulation is the major type of operation. It is performed at marriage and at delivery. The majority of the respondents in this study were defibulated naturally by their husbands. This is in fact a long and painful process which can take from 2 to 12 weeks to complete(2). Sometimes the problem persists much longer, up to two years, and the patients presents with an infertility problem(11). Serious injuries such as perineal tears could be inflicted on women when their husbands desperately tried to defibulate them with knives(1). The men may hurt themselves also during the procedure and cases with ulcers to the glans penis are sometimes treated (Dirie, personal experience).
The risk of medical complications after female circumcision is very high as revealed by the present study. Complications which cause the death of the young girls must be a common occurrence especially in the rural areas where health services do not exist. But even in urban centres people hesitate to seek medical help for their complications or do not accept the help offered as shown by the present study. If documented during the weeks just after circumcision the medical complications would probably be still more severe than when reported by the women many years after the operation. Dribbling urine incontinence, painful menstruations, haematocolpos and painful intercourse are facts that Somali women have to live with--facts that strongly motivate attempts to change the practice of female circumcision.
Reprint requests to Dr. M.A. Dirie
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