Diagnosis, Management, and Treatment of Female Genital Mutilation or Cutting in Girls

CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care
Diagnosis, Management, and Treatment

of Female Genital Mutilation or Cutting
in Girls
Janine Young, MD, FAAP,a Nawal M. Nour, MD, MPH, FACOG,b Robert C. Macauley, MD, FAAP,c Sandeep K. Narang, MD, JD, FAAP,d
Crista Johnson-Agbakwu, MD, MSc, FACOG,e SECTION ON GLOBAL HEALTH, COMMITTEE ON MEDICAL LIABILITY AND RISK
MANAGEMENT, COMMITTEE ON BIOETHICS
Female genital mutilation or cutting (FGM/C) involves medically unnecessary abstract

cutting of parts or all of the external female genitalia. It is outlawed in the
United States and much of the world but is still known to occur in more than
30 countries. FGM/C most often is performed on children, from infancy to a
Department of General Pediatrics, Denver Health Refugee Clinic, and
adolescence, and has significant morbidity and mortality. In 2018, an Human Rights Clinic, Denver Health and Hospitals and School of
estimated 200 million girls and women alive at that time had undergone FGM/ Medicine, University of Colorado Denver, Denver, Colorado; bAfrican
Women’s Health Center, Department of Obstetrics and Gynecology,
C worldwide. Some estimate that more than 500 000 girls and women in the Brigham and Women’s Hospital and Harvard Medical School, Harvard
United States have had or are at risk for having FGM/C. However, pediatric University, Boston, Massachusetts; cDepartment of Pediatrics, Oregon
prevalence of FGM/C is only estimated given that most pediatric cases remain Health and Science University, Portland, Oregon; dDivision of Child
Abuse Pediatrics, Ann and Robert H. Lurie Children’s Hospital of
undiagnosed both in countries of origin and in the Western world, including in Chicago and Department of Pediatrics, Feinberg School of Medicine,
the United States. It is a cultural practice not directly tied to any specific Northwestern University, Chicago, Illinois; and eRefugee Women’s
Health Clinic, Department of Obstetrics and Gynecology, Valleywise
religion, ethnicity, or race and has occurred in the United States. Although it is Health Medical Center and Office of Refugee Health, Southwest
mostly a pediatric practice, currently there is no standard FGM/C teaching Interdisciplinary Research Center, School of Social Work, Watts College
of Public Service and Community Solutions, Arizona State University,
required for health care providers who care for children, including Phoenix, Arizona
pediatricians, family physicians, child abuse pediatricians, pediatric
urologists, and pediatric urogynecologists. This clinical report is the first Clinical reports from the American Academy of Pediatrics benefit from
expertise and resources of liaisons and internal (AAP) and external
comprehensive summary of FGM/C in children and includes education reviewers. However, clinical reports from the American Academy of
Pediatrics may not reflect the views of the liaisons or the
regarding a standard-of-care approach for examination of external female organizations or government agencies that they represent.
genitalia at all health supervision examinations, diagnosis, complications, The guidance in this report does not indicate an exclusive course of
management, treatment, culturally sensitive discussion and counseling treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.
approaches, and legal and ethical considerations.
All clinical reports from the American Academy of Pediatrics
automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time.
To cite: Young J, Nour NM, Macauley RC, et al. AAP SECTION

ON GLOBAL HEALTH, AAP COMMITTEE ON MEDICAL LIABILITY
AND RISK MANAGEMENT, AAP COMMITTEE ON BIOETHICS.
Diagnosis, Management, and Treatment of Female Genital
Mutilation or Cutting in Girls. Pediatrics. 2020;146(2):
e20201012
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PEDIATRICS Volume 146, number 2, August 2020:e20201012 FROM THE AMERICAN ACADEMY OF PEDIATRICS 1
BACKGROUND a traditional rite of passage, and/or risk for having FGM/C performed, but
Female genital mutilation or cutting upholds prescribed religious beliefs these estimates are projections based
(FGM/C)* is currently outlawed in (although no sacred texts recommend on country of origin prevalence data
much of the world. The United this practice).6,7 FGM/C is and may, therefore, not be precise or
Nations,1 the World Health predominantly performed on children accurate.13 To date, no reliable data
Organization (WHO),2 the and adolescents ranging in age from exist quantifying the true number of
International Federation of Obstetrics newborn infants to 15 years; the girls and women residing in the
and Gynecology,3 and the American typical age varies by region of the United States who have had FGM/C
Medical Association4 are among world, country, state, province, and performed.13
multiple organizations that even town or village8 (see Fig 2).
The majority of FGM/C occurs in 30
unequivocally oppose all forms of However, the vast majority of
African and Middle Eastern countries,
FGM/C (see Table 1). medical literature, teaching, and
with highest prevalence in Egypt,
research is focused on chronic
FGM/C involves medically Somalia, Guinea, Djibouti, Mali, Sierra
issues affecting women of
unnecessary cutting of parts or all of Leone, Sudan, and Eritrea.14 However,
childbearing age and on the
the external female genitalia, FGM/C also occurs with unknown
management of FGM/C during
including the clitoris, prepuce, labia frequency in Yemen, Oman, the
pregnancy and the peripartum and
United Arab Emirates, Bahrain,
minora, and labia majora. FGM/C may postpartum periods.9,10
be associated with significant northern Iraq, India, Malaysia, and
morbidity and mortality and is not To date, there are neither national Indonesia15 and has been reported to
associated with any medical benefit. nor international clinical practice occur sporadically in Russia16,17 and
Notwithstanding this morbidity, it is guidelines that are specifically Colombia.18 The practice of FGM/C is
still performed and has been focused on FGM/C in infants and not uniformly performed throughout
practiced in many cultures for prepubertal and pubertal girls. any given country and may be
thousands of years, predating clustered on the basis of economic
This clinical report’s primary goal is
Judaism, Christianity, and Islam.5 status, level of education, rural versus
to educate pediatric health care
Historically and in present-day, FGM/C urban geographic location, ethnic
providers on the continued
is a cultural practice not directly tied and/or tribal affiliation, and religious
occurrence of FGM/C, the populations
to any specific religion, ethnicity, or beliefs. In half of the countries with
that it affects, diagnosis,
race and has been reported to still available data on FGM/C prevalence,
complications, treatment
occur throughout the world, including most girls have had FGM/C
options, and the provision of
in the United States, but with higher performed before 5 years of age
culturally sensitive counseling,
prevalence in parts of the Middle (see Fig 2).
all while taking into consideration
East, Asia, and Africa (see Fig 1). the legal and ethical aspects of Although it is illegal in the United
Reasons why FGM/C is performed a practice that is illegal in the States, FGM/C has been reported in
vary by region and culture and may United States and much of the world the United States in sporadic cases
include a belief that it increases (see Table 2). over the past several years.19,20 The
marriageability, preserves virginity, federal Department of Justice
improves hygiene, perpetuates prosecuted its first case against a US
PREVALENCE physician accused of having
* Currently, there are few experts in the United National and international data on the performed FGM/C across state lines
States who care for children and teenagers with prevalence of FGM/C in children and in up to 100 children (see The Law
FGM/C (see Table 4 for a link to access regional
specialists). As such, it is of utmost importance to adolescents are difficult to obtain and and FGM/C in Minors in the United
identify regional specialists, including child abuse are based on either maternal report States for further current case
pediatricians, gynecologists, urologists, and or estimates derived from data on the details).21 At of time of writing, the
mental health providers, with whom to collaborate adult female population who present charges were dismissed by the
if providing medical care for children and mainly for obstetrical care. The district judge of the Eastern District
teenagers affected by or at risk for FGM/C. FGM/C
is an accepted term adopted by many United Nations Children’s Fund of Michigan.22 This specific case is
international organizations and in medical estimated that in 2018, 200 million focused on the practice of FGM/C in
research papers and, as such, will be used girls and women alive at that time the Dawoodi Bohra community in
throughout this document.9,12,16 Infibulation refers had undergone FGM/C worldwide.11 India and among a subset of the
to type III FGM/C (see FGM/C Types and
Some authors estimate that more Dawoodi Bohra immigrant
Classification in addition to Fig 4). Defibulation
refers to a surgical procedure that opens the scar than 500 000 girls and women who community in the United States. The
formed in patients with type III FGM/C (see live in the United States (as of 2012) illegal practice of US families sending
Defibulation). have had FGM/C performed or are at their children abroad to have FGM/C

2 FROM THE AMERICAN ACADEMY OF PEDIATRICS
TABLE 1 FGM/C Recommendations
Recommendations
FGM/C is illegal in the United States.
FGM/C is a violation of human rights.
FGM/C has no medical benefit.
FGM/C is associated with serious and potentially life-threatening complications that can have lifelong impacts on health.
Health care providers should not perform any type of FGM/C on female infants, girls, or teenagers.
Health care providers caring for girls at risk for FGM/C should actively counsel families against performing FGM/C, including when families travel to countries
where FGM/C is practiced.
A genital examination allows health care professionals to identify FGM/C and other medical findings of significance.
If genital examination findings are equivocal for the presence of FGM/C and risk factors for FGM/C are present, a specialist trained in identification of FGM/C
should be consulted (see Table 4).
The management of FGM/C should include complete documentation of clinical findings and the use of ICD-10 coding.
Health care providers should recommend defibulation for all girls and teenagers with type III FGM/C, irrespective of whether complications are currently
present.
performed (also known as “vacation FGM/C TYPES AND CLASSIFICATION significant long-term morbidity (see
cutting”) is also presumed to The WHO has classified FGM/C into Complications and Management)
occur.23,24 However, prevalence data four distinct types (see Table 3), with (Figs 3–11). To better delineate
are nonexistent to date.13 type III associated with the most specific findings, the WHO has also
included subtypes of FGM/C,
categorized as Ia and Ib, IIa–IIc, and
IIIa and IIIb (see Fig 12). However,
the practice of FGM/C is not
standardized, and physical findings
may overlap between types and
subtypes (see Figs 5 and 6).
Type I FGM/C is classified as
cutting of the glans or part of
the body of the clitoris and/or
prepuce; type II includes
excision of the clitoris and labia
minora, with or without excision
of the labia majora; type III,
infibulation, includes cutting and
apposing the labia minora and/or
majora over the urethral meatus and
vaginal opening to significantly
narrow it and may include
clitoral excision (Figs 10 and 11);
and type IV includes piercing,
scraping, nicking, stretching, or
otherwise injuring the
external female genitalia without
removing any genital tissue
and includes practices that do not fall
into the other three categories
(Fig 13).
Prevalence of FGM/C subtypes is
mainly influenced by ethnicity and
region. Surveys of girls and women
FIGURE 1 older than 15 years reveal that
FGM/C global prevalence. Countries where FGM/C is practiced with unknown frequency and not approximately 10% of cases are
pictured on this map include Oman, the United Arab Emirates, Bahrain, India, Malaysia, Russia, and
Colombia.15–18 South Sudan seceded from Sudan in 2011 but is not noted on this map.107 Repro-
FGM/C type III, or infibulation,
duced with permission from United Nations Population Fund. Demographic Perspectives on Female although these numbers are based on
Genital Mutilation. Copyright © United Nations Population Fund 2015. self-report and likely under- or

PEDIATRICS Volume 146, number 2, August 2020 3
note the lack of training in diagnosis,
management, and cultural and legal
aspects of care in adult women.29–32
One recent US study revealed that of
79 general pediatricians surveyed,
73% had received no previous FGM/C
education, 89% did not feel confident
in their ability to identify FGM/C
types, and frequency of performing
external genital examinations on
female patients at health supervision
visits was inversely related to the age
of the patient (with 75% performing
examinations on infants, down to only
8% in 17- to 18-year-olds).28 In
literature from other high-income
countries with immigrant populations
from regions where FGM/C is
prevalent, pediatricians have
reported identifying FGM/C in
pediatric patients, managing
complications from remote and
recent procedures, and, in some
instances, being asked to perform
FGM/C in children.9,33,34 However,
one survey conducted in Australia
revealed that of pediatricians
surveyed, most reported neither
discussing nor examining children for
FGM/C.34,35
CLINICAL HISTORY TAKING

FIGURE 2 For children with possible risk factors
Maternal report of age that girls have undergone FGM/C, by country. Reproduced with permission for FGM/C (eg, mother or sibling with
from UNICEF. Female Genital Mutilation/Cutting: A Statistical Overview and Exploration of the
Dynamics of Change. New York, NY: UNICEF; 2013:41. Copyright © United Nations Children’s a history of FGM/C, country of origin,
Fund 2013. birth country, and/or history of travel
to a country where FGM/C is
practiced), it is recommended that
overestimate the actual prevalence of KNOWLEDGE OF, ATTITUDE ABOUT, AND clinical assessment of FGM/C status
type III FGM/C.8 The practice of PRACTICE OF FGM/C IN THE UNITED be integrated into routine pediatric
infibulation, the removal and STATES care. Nonetheless, it can be
apposition of the labia minora and/or Knowledge of FGM/C is believed to be challenging. It is of utmost
labia majora with or without cutting limited among US pediatric providers importance for the pediatric health
of the clitoris, is concentrated in because there are no nationally care provider to establish a trusting
northeastern Africa in Djibouti, required courses on diagnosis of type, relationship with the child or
Eritrea, and Somalia. Data management, or treatment of FGM/C teenager and her family to allow for
extrapolated from 2004 to 2008 East for medical students, residents, or nonjudgmental questions and
African regional surveys of girls and fellows in general pediatrics, family ongoing counseling. Experts
women 15 years and older revealed medicine, adolescent medicine, child suggest that health care providers
that 82% to 99% reported to have abuse pediatrics, urology, or ask the patient or parent the term
had undergone FGM/C, and of these gynecology.9,26–28 Instead, existing they use to name female genital
cases, 34% to 79% were type III studies from the United States are cutting. Use of the word
(Somalia having the highest focused on nurse midwives and mutilation is not recommended when
prevalence of type III).25 obstetricians and gynecologists and discussing FGM/C with patients and

TABLE 2 Timeline of International Legislation Against FGM/C may also be very limited.
Country Year Legislation Enacted a Understanding each girl’s and
Benin 2003
mother’s current knowledge and
Burkina Faso 1996 perception of FGM/C, addressing
Central African Republic 1966, 1996b fears, providing age-appropriate
Chad 2003 education about pelvic anatomy, and
Côte d’Ivoire 1998 sharing information about the
Djibouti 1995, 2009b
Egypt 2008
importance of the annual physical
Eritrea 2007 examination can facilitate ongoing
Ethiopia 2004 rapport and engagement with health
The Gambia 2015108 care. In addition, some girls or
Ghana 1994, 2007b parents may request a female health
Guinea 1965, 2000b
Guinea-Bissau 2011
care provider as well as a female
Iraq (Kurdistan region) 2011 interpreter. For girls at risk for FGM/
Kenya 2001, 2011b C, it is advisable that efforts be made
Mauritania 2005 to honor this request, if at all possible,
Niger 2003 given social and cultural expectations.
Nigeria (some states) 1999–2006
Senegal 1999 It is important for health care
Somalia 2012 providers to assess each patient
Sudan (some states) 2008–2009
Togo 1998
individually and make no
Uganda 2010 assumptions about her and her
United Republic of Tanzania 1998 parents’ beliefs regarding FGM/C.
Yemen 2001 Mothers and fathers may or may not
Reproduced with permission from United Nations Children’s Fund. Female Genital Mutilation/Cutting: A Statistical Over- hold discordant views about FGM/C,
view and Exploration of the Dynamics of Change. New York, NY: United Nations Children’s Fund; 2013:9. Copyright © and some clinical experts suggest that
UNICEF 2013.
a Bans outlawing FGM/C were passed in some African countries, including Kenya and Sudan, during colonial rule. This mothers who have themselves
table includes only legislation that was adopted by independent African nations and does not reflect earlier rulings. undergone FGM/C may nonetheless
b Later dates reflect amendments to the original law or new laws.
oppose subjecting their daughters to
this practice. Instead, treating
patients and caregivers with respect,
caregivers because it is potentially may initially withhold information sensitivity, and professionalism will
inflammatory and also difficult to about previous FGM/C. encourage them to return and
translate (and may not be supports health-seeking behavior.
understood). When caring for girls with or at risk
for FGM/C, it is important to In families with risk factors for FGM/C,
Given that girls who had FGM/C approach FGM/C discussion, physical including having a mother and/or
performed at a young age may not examination, and counseling with other girls who have already been cut
recall being cut (as well as the fact cultural sensitivity. Girls’ genitalia in the family, it is advisable to inquire,
that parents or primary guardians may have never been examined in a nonthreatening manner, whether
may not reveal a history of FGM/C to before, although they may have had the parents are planning to perform
their children), obtaining a history of multiple physical examinations in the FGM/C on their daughter. Raising
FGM/C from the girl alone may yield United States or abroad.28 Girls and such a sensitive topic may elicit
little relevant clinical information. mothers who have been cut may be various emotions, but this is a vital
Instead, it is advisable that the FGM/C afraid to seek care from a health care educational opportunity to reiterate
clinical history taking include both provider because of concerns about child safety, the morbidity and
the girl and parent or guardian disapproval or previous negative mortality associated with FGM/C, and
once rapport has been established. experiences being used to teach its legal consequences. Such
Similarly, some parents or guardians trainees or other health care discussions may occur over multiple
may not be aware that FGM/C providers about FGM/C; many will visits, and it is recommended to
performed in the country of seek a physician’s care only if there is revisit these discussions, particularly
origin before immigration is not a health problem. Irrespective of their if the child is being seen before a trip
prosecutable in the United States (see culture, girls’ and mothers’ to countries where FGM/C is still
The Law and FGM/C in Minors in the knowledge of female anatomy, practiced. Whether to have this
United States) or may fear judgment reproductive health, family planning, discussion in front of the girl depends
from US medical providers, so they and sexually transmitted infections on the developmental age of the child,

TABLE 3 FGM/C ICD-10 Coding and WHO Classification
FGM/C Type ICD-10 Code109 WHO Classification (2016)
Female genital mutilation, N90.810
unspecified
Female genital mutilation, N90.811 Partial excision of the clitoris and/or prepuce
type I
— Ia: removal of prepuce only
— Ib: partial or totala removal of clitoris and prepuce
Female genital mutilation, N90.812 Partial or totala removal of the clitoris and labia minora, with or without excision of the labia majora
type II
— IIa: removal of labia minora only
— IIb: partial removal of the clitoris and labia minora
— IIc: partial removal of the clitoris, labia minora and majora
Female genital mutilation, N90.813 Infibulation: narrowing of the vaginal orifice by cutting and apposing the labia minora and/or labia majora over
type III the vaginal opening; may include excision of the clitoris
— IIIa: removal and apposition of the labia minora
— IIIb: removal and apposition of the labia majora
Other female genital N90.818 Unclassified (all other harmful procedures for non-medical purposes), including piercing
mutilation
— IV
—, not applicable.
a Although WHO classification describes total removal of the clitoris, it is the glans or the glans and part of the body of the clitoris that is cut.110
her degree of understanding, and the providers are both aware that EXTERNAL FEMALE GENITAL
dynamics within the family. education about FGM/C medical EXAMINATION: STANDARDS AND
Encouraging parents to reevaluate complications and illegality has been DOCUMENTATION
this practice in a nonjudgmental discussed and aware of what specific Bright Futures: Guidelines for Health
manner and impressing on them that issues have and have not been Supervision of Infants, Children, and
FGM/C causes medical complications, discussed. Similarly, given that FGM/ Adolescents, Fourth Edition,
has no medical indications, and is also C performed overseas and before US recommends that “each visit include
against the law (with associated legal emigration does not constitute a complete physical examination.” A
consequences) will hopefully a violation of US law, it is of utmost complete physical examination
facilitate reconsideration of this importance to document past history includes assessment of genitalia from
practice. It is also essential to and timing of FGM/C in the chart so birth to age 21.36
document these discussions in the that it is clear that there are no legal
It is recommended that pediatricians
medical chart so that health care ramifications for the family.
and other health care providers
include genital inspection as part of
all health supervision examinations
and be knowledgeable about the
variants of normal genital anatomy
and the signs of previous genital
cutting.33
The external genital examination in
girls should include the identification
of the prepuce, clitoris, and labia
minora and majora (see Figs 14–16),
and the examination should be
performed in frog-leg position with
chaperone use documented, per
FIGURE 3 recommendations of the American
Prepubertal female with labial adhesions, Academy of Pediatrics.37 In
no FGM/C. (Reprinted with permission from prepubertal girls, it may be more
American Academy of Pediatrics. Visual Di-
agnosis of Child Abuse on CD-ROM. 3rd ed. Elk FIGURE 4 difficult to identify the clitoris, and in
Grove Village, IL: American Academy of Pediat- Periclitoral adhesions, 18-month-old female these cases, the prepuce may need to
rics; 2008.) patient, no FGM/C (photo credit: J.Y.). be partially retracted to facilitate

consulted, although currently, there
are few such specialists in the United
States (see Table 4 for a link to access
regional specialists). However, given
the subtleties of some FGM/C, it is
assumed that not all cases will be
identified.
If FGM/C is suspected to have

occurred recently, it may also be
difficult to confirm on physical
examination without prompt
evaluation by a specialist. The
genitalia are highly vascularized
tissues, healing occurs quickly, and
less invasive cutting may easily be
missed in some cases, given minimal
or only subtle scarring.
If FGM/C is identified on examination,

FIGURE 5 it is advisable that the clinician
Type IIb or IIIa FGM/C in a prepubertal girl (excised clitoris, prepuce, partially excised right labia discuss findings with the caregiver
minora, absent left labia minora, and possible partial anterior fusion of excised labia minora
covering urethral meatus and proximal vaginal introitus). This photo was reviewed by three FGM/C and/or child if the child is old enough
experts (J. Abdulcadir, C.J.A, and J.Y), and consensus was either type IIb or IIIa. Arrows were added to participate in medical decision-
by J.Y. (Reprinted with permission from Graham EA. Ritual female genital cutting [RFGC] PowerPoint making. Medical complications,
slides. 2014. Available at: https://ethnomed.org/resource/ritual-female-genital-cutting-rfgc-powerpoint- depending on the type of FGM/C
slides/. Accessed April 30, 2020.)
diagnosed, should be reviewed with
the caregiver and/or child, as well as
identification. Similarly, the labia physical examination, particularly in when to return for care if any of these
minora is less developed, and it is prepubertal girls. Similarly, complications develop (see
advisable that efforts be made to prepubertal labial adhesions may be Complications and Management). If
identify this structure as well. miscategorized as FGM/C (see Figs an older child or teenager is unaware
Although not systematically studied, 3–6). If genital examination findings that she has had FGM/C performed
anecdotal experience by some experts are equivocal for the presence of (as may be the case if a girl had FGM/
suggests that types I, II, and IV FGM/C FGM/C and risk factors for FGM/C are C performed at a young age), it is
and even some type III subtypes may present, a specialist trained in important that a culturally sensitive
be difficult to recognize during the identification of FGM/C should be approach be taken to further discuss
her diagnosis with her (see the
Appendix for further guidance).
Although not systematically studied,
FGM/C is a community practice, and
in some cultures, aunts, grandparents,
or other figures of authority may
make the decision to perform
FGM/C on a child.38 In these cases,
theoretically, a parent may also not
know of a child’s previous FGM/C. It
is suggested that a thoughtful,
supportive discussion occur with the
FIGURE 6
Type Ib FGM/C, scarring with excised clitoris and prepuce, or type IV FGM/C with linear scar from primary caregivers to inform them of
superficial cutting with adhesions, Tanner stage 5 female patient. This photo was reviewed by three the diagnosis, associated potential
FGM/C experts (J. Abdulcadir, C.J.A., and J.Y.), and it was unclear if it was type 1b or type IV on the medical issues, and treatment, when
basis of photos. The author of the source of the photo identifies the photo as type IV FGM/C.
(Reprinted with permission from Creighton SM, Dear J, de Campos C, Williams L, Hodes D. Multi-
clinically indicated. Given that such
disciplinary approach to the management of children with female genital mutilation [FGM] or information may be distressing, it is
suspected FGM: service description and case series. BMJ Open. 2016;6[2]:e010311.) advised to offer mental health

may facilitate timely referral to
gynecologic or urologic specialists, if
needed. However, a recent review of
state-level hospital discharge data in
Arizona revealed that from 2008 to
2014, only 243 cases of FGM/C had
been documented, as identified by
International Classification of
Diseases, Ninth Revision and ICD-10
codes, and that of these 243 cases,
none were documented in children
younger than 18 years (C.J.A,
unpublished observations). As
context, the Population Reference
Bureau estimates that 7459 women
and children are at risk for FGM/C in
Arizona, suggesting that FGM/C is not
being documented consistently by
health care providers.40
FIGURE 7
Type IIa FGM/C, excision of labia minora only, Tanner stage 5 female patient. (Reprinted with permission
of Jasmine Abdulcadir. Copyright © Jasmine Abdulcadir. Also published in Abdulcadir J, Catania L, COMPLICATIONS AND MANAGEMENT
Hindin MJ, Say L, Petignat P, Abdulcadir O. Female genital mutilation: a visual reference and learning
tool for health care professionals. Obstet Gynecol. 2016;128[5]:959.) Immediate Health Complications
Health care providers who work with
professional support to caregivers, as Diseases, 10th Revision (ICD-10) children and live in countries with
indicated. coding,39 as indicated. A guide to intermediate and high prevalence of
ICD-10 coding and definitions and FGM/C are likely to see immediate
descriptions of FGM/C subtypes is health complications; however, such
CODING AND DOCUMENTATION provided in Table 3. In the future, a situation is likely rare in the United
The management of FGM/C should appropriate coding will allow for States.41 Exceptions will be newly
include complete documentation of better estimates of pediatric FGM/C arrived immigrants who underwent
clinical findings and use of the prevalence. Additionally, clinical FGM/C just before entering the
International Classification of documentation of FGM/C findings United States, girls who have recently
returned to the United States after
undergoing FGM/C while temporarily
overseas, or FGM/C that has been
performed in the United States. In
general, medical complications
become more severe with
progression from type I to type III,
tending to reflect the amount of tissue
being removed. If the clitoral dorsal
artery or labial branches of the
pudendal artery are cut, hemorrhage
has been documented in the range of
4% to 19%. Active hemorrhage,
subsequent hypotension,
hypovolemic shock, and death may
occur in these cases.42,43
Given the potential use of traditional
FIGURE 8 nonsterile instruments, girls with
Type IIb FGM/C, partial or total clitoridectomy and excision of labia minora, Tanner stage 5 woman. (Reprinted
FGM/C are at risk for acute infections.
with permission of Jasmine Abdulcadir. Copyright © Jasmine Abdulcadir. Also published in Abdulcadir J,
Catania L, Hindin MJ, Say L, Petignat P, Abdulcadir O. Female genital mutilation: a visual reference and Girls with type III FGM/C most often
learning tool for health care professionals. Obstet Gynecol. 2016;128[5]:959.) have their legs bound for up to

need to restrain a girl who was not
anesthetized during the procedure42
(Table 5).
If a girl is seen with any immediate
complications, it is recommended that
the health care provider refer for
appropriate emergency care and the
patient receive vaccination against
tetanus. Once stabilized, it is
recommended to consult a health
provider with FGM/C expertise (see
Table 4) to determine the need for
medical and/or surgical management.
Although there are no data that
directly link FGM/C to acquisition of
HIV, hepatitis B, or hepatitis C, some
FIGURE 9
Type IIc FGM/C, partial or total clitoridectomy, excision of the labia minora and majora, Tanner stage clinical experts recommend testing
5 woman. (Reprinted with permission of Jasmine Abdulcadir. Copyright © Jasmine Abdulcadir. Also for these infections at the initial visit
published in Abdulcadir J, Catania L, Hindin MJ, Say L, Petignat P, Abdulcadir O. Female genital and at least 6 months after cutting
mutilation: a visual reference and learning tool for health care professionals. Obstet Gynecol. 2016;
128[5]:959.)
has occurred.44 As in all children, it is
advised that hepatitis B vaccination
be offered to girls with FGM/C if they
1 week after cutting (standard have also been reported. Difficulty
are neither immune nor infected.
practice in type III cases, reportedly urinating, both from pain and
to facilitate scar formation). Such deliberate decreased liquid intake, is In cases in which a girl has been
prolonged binding facilitates bacterial common.41 The urethra, vagina, and/ recently cut, it is recommended to
overgrowth and prevents wound or rectum may also be inadvertently offer mental health supports for her,
healing. Girls may suffer from cut during FGM/C. Fractures of the as indicated. Refer to Reporting Child
cellulitis or wound abscesses; clavicle, femur, or humerus also have Abuse and Ethical Analysis regarding
gangrene, septic shock, and tetanus been reported, resulting from the scenarios in which child abuse
reports are recommended.
Long-Term Complications
Studies reveal that girls and women
with type III FGM/C are also at higher
risk of long-term health complications
than those with type I, II, or IV FGM/
C. A systematic review of the
literature reveals that long-term
health complications include
dysmenorrhea as well as
psychosexual, infertility, and urinary
problems.42 However, physical and
psychological complications are not
necessarily proportionate to the
FGM/C type. Although the authors of
one study state that the relative risk
of obstetric complications (including
increased cesarean delivery rates), of
the need for infant resuscitation, of
FIGURE 10 stillbirths, and of infants with low
Type IIIb FGM/C, with significant narrowing of the introitus from stitching of the labia minora, Tanner birth weight increases with the
stage 5 woman. (Reprinted with permission of Jasmine Abdulcadir. Copyright © Jasmine Abdulcadir.
Also published in Abdulcadir J, Catania L, Hindin MJ, Say L, Petignat P, Abdulcadir O. Female genital
severity of FGM/C, data are limited,
mutilation: a visual reference and learning tool for health care professionals. Obstet Gynecol. 2016; and it is likely that the combination of
128[5]:961.) obstructed labor and substandard

Urinary Issues
The narrow neo-introitus and scar in
type III FGM/C create a dark, moist,
and unventilated area surrounding
the urethra. Urine can stagnate
beneath the scar and promote
abnormal bacterial growth. As
a result, girls who are infibulated can
experience chronic urinary tract
infections. With recurrence of UTI,
suppressive antimicrobial medication
is an option, although defibulation is
preferable; however, currently there
are no known systematic studies
evaluating the efficacy of prophylactic
FIGURE 11
Type IIIb FGM/C in a Tanner stage 5 17-year-old with severe dysmenorrhea preventing her from going antibiotic treatment or defibulation in
to school during menstrual flow (photo courtesy of N.N.). preventing recurrent UTIs associated
with FGM/C.53
health care systems contribute to very rare cases, hematocolpos and In general, clinical experience
such complications (Tables 6 hematometra have been documented. indicates that girls who are
and 7).45 infibulated may describe their
Other painful complications arise urinary stream as being slow and
Secondary analysis of cesarean when remnant foreign bodies are left having a dripping quality. As the urine
delivery rates has revealed that in the scar during the initial exits the urethra, it trickles under the
health care provider unfamiliarity procedure. These can produce sharp scar and then drips past the neo-
with defibulation and/or other pains when sitting and walking. Cut introitus. Patients also may complain
management options for FGM/C may or trapped nerve fibers have also of overactive bladder on the one hand
increase the risk of cesarean been documented, creating very or straining and urinary retention on
deliveries in some cases.46,47 painful neuromas. In both of these the other. These issues may be
situations, defibulation and removal attributable to injury of the
Long-term complications can be
of the foreign body or neuroma are urethra, resulting in urinary
placed into 7 major categories: pain,
recommended.51 strictures and stenosis and
urinary issues, infections, scarring,
requiring cystoscopy or urethral
infertility, sexual dysfunction,42,48 Dyspareunia in sexually active dilation. It is also possible for the
mental health issues,49,50 and other teenagers with type III FGM/C has obstructing scar to enable urinary
(Table 5).
been seen (see Future Infertility) and crystals to deposit and, as a result,
treatment includes defibulation.52 form urinary stones.54 These patients
Pain routinely experience sharp pains and
Pain is a common long-term One study followed 40 Somali women require defibulation for stone
complication after type III FGM/C and whose primary indications for removal.
can also be present in patients with defibulation were pregnancy (30%),
type I and II FGM/C. In type III FGM/ dysmenorrhea (30%), apareunia Scarring and Other Postinflammatory
C, the narrow neo-introitus creates (20%), or dyspareunia (15%). Of the Reactions
a closed environment that can 32 patients surveyed, 94% stated Keloid formation is rare, although not
obstruct urinary and menstrual flow. they would highly recommend unknown in FGM/C cases. The main
Because of the scarring that obstructs defibulation to others; 100% of problem with the infibulated scar is
the introitus, the menstrual flow of patients were pleased with the its obstructive nature. However, other
women and teenagers with results, felt their appearance had complications in type II FGM/C
infibulation can last longer than improved, and were sexually satisfied, include unintended labial fusions and
usual, rendering them unable go to suggesting that the symptoms of cysts (fluid-filled, sebaceous, or
school during this time (see Fig 11). teenagers who have undergone FGM/ inclusion cysts or abscesses). There
Menstruation may be painful and may C and are experiencing dysmenorrhea are multiple case reports
become dark and foul smelling will also be improved by documenting epidermal cysts
because of the retention of blood. In defibulation.52 associated with all types of FGM/C.

Of note, large epidemiologic studies
conducted in low- or middle-income
countries where both FGM/C and HIV
and/or hepatitis B are prevalent have
not revealed an association between
FGM/C and HIV and/or hepatitis B
infections.44,58,59 The authors of these
studies did not evaluate risk around
the time of cutting but months to
years after the cutting occurred. To
our knowledge, no studies have
specifically addressed hepatitis C
infection risks. However, given that
FGM/C is often performed with
unsterile equipment that may be
shared between patients, some
experts recommend testing girls with
FGM/C for these blood-borne
infections.
Future Infertility
Infertility for women with type III
FGM/C is influenced by anatomic and
psychological barriers as well as from
possible recurrent gynecologic
infections. In a Sudanese case-control
hospital-based study of 99 women
without hormonal, iatrogenic, or
male-partner risk factors for
infertility a diagnostic laparoscopy
was performed, and it was found that
FIGURE 12 primary infertility was associated
WHO FGM/C subtype diagrams. A, Female genital mutilation (FGM) type 1. B, FGM type 2. World Health
Organization. Copyright © World Health Organization 2016. Also published in Abdulcadir J, Catania L, with the increased anatomic damage
Hindin MJ, Say L, Petignat P, Abdulcadir O. Female genital mutilation: a visual reference and learning inflicted by FGM/C.60 Repeated
tool for health care professionals. Obstet Gynecol. 2016;128(5):959–960. attempts at penetration through the
infibulated scar may be painful and
Some cysts have been documented to suppositories, this is an alternative difficult, and stretching of the
grow up to 12 cm in size and are not treatment. For girls and teenagers infibulated introitus may take
only extremely painful but also with chronic infections, defibulation months. The learned association
become problematic for ambulation by an adolescent or general between sexuality and pain may
and sitting.55,56 Dissecting the cyst gynecologist experienced with a have significant negative effect on
and defibulating the patient is managing FGM/C is recommended. the woman’s willingness to have
necessary in these cases (see Fig 17). intercourse and, thereby, on fertility.
A study in rural Gambia of teenagers In general, if there are any issues
Other Infections and women (15–54 years) with related to FGM/C that negatively
Given the infibulated scar, this clinically diagnosed type I or II FGM/C affect sexual health, referral to
enclosed environment fosters (N = 671) also revealed a higher appropriate mental health supports is
bacterial and fungal growth and prevalence of bacterial vaginosis and advisable for both women and their
predisposes girls to chronic or herpes simplex virus 2 compared partners.
recurrent vaginal infections. In these with teenagers and women without
cases, oral antifungal and FGM/C but did not reveal an Sexuality
antimicrobial medications are increased risk for perineal or anal There are currently no studies that
recommended. If the patient’s neo- damage, vulvar tumors, dyspareunia, have been specifically focused on
introitus is not too small and she is infertility, organ prolapse, or other sexuality in teenagers with FGM/C.
comfortable with introducing vaginal reproductive tract infections.57 The impact of FGM/C on female

small cross-sectional study of
Egyptian women and girls (N = 204,
ages 14–19 years), those with and
without FGM/C were compared, and
a significantly higher prevalence of
somatization, depression, and anxiety
was found in those with FGM/C.49
Defibulation
Defibulation, also known as
deinfibulation, is the procedure that
opens the infibulated scar in type III
FGM/C and exposes the vaginal
introitus and urethral opening. In
general, in some regions of the world,
including Djibouti, defibulation is
most often performed in newly
married teenagers by a traditional
birth attendant or midwife so that
sexual intercourse may occur. In other
regions, including North Sudan,
Somalia, and areas in southern Egypt,
the husband opens the neo-introitus
over time through ongoing attempts
at penetration. However, some
teenagers and women who have
access to medical care may have
defibulation performed by a medical
professional at marriage or after their
official engagement.
FIGURE 12 Teenagers who are infibulated may
Continued.
present to health care providers
requesting defibulation. Given the
sexuality has been evaluated in a few date, there are no conclusive results significant morbidity associated with
studies in adult women. However, the revealing long-term benefits. If type III FGM/C, experts believe that
lack of standardization of FGM/C teenagers inquire about the option of defibulation should be recommended
subtype studied and the use of reconstructive surgical repair, it is for all girls and teenagers with type
nonvalidated questionnaires make important to review the fact that III FGM/C, particularly when
interpretation of results difficult. there is still inadequate data that complications are currently present.
Some studies reveal that women with assure successful outcomes, including Similarly, teenagers who are pregnant
FGM/C have reported less sexual a decrease in pain and increased should also be counseled regarding
desire, arousal, orgasms, and sexual pleasure.65,66 risks during and after pregnancy and
satisfaction compared with women should be strongly encouraged to
without FGM/C61 as well as increased
Mental Health
undergo defibulation.
rates of dyspareunia.62 Other There has been limited high-quality
research has revealed no association research on the effects of FGM/C on Of note, given that girls and teenagers
between FGM/C and sexual the mental health of girls and women. who are infibulated have varying
intercourse frequency and that One 2010 systematic review of the degrees of obstruction of urinary or
women with FGM/C also initiated literature included 17 studies of menstrual flow, have varying degrees
sexual intercourse more than women women with and without FGM/C (N = of pain, and/or have risks for normal
without FGM/C.63,64 12 755) and revealed insufficient vaginal delivery, such signs and
evidence to support or refute the link symptoms should underscore the
Surgical clitoral reconstruction is an of FGM/C to specific mental health medical necessity for treatment.
emerging area of study. However, to diagnoses.48 In a more recent 2017 Given the medical necessity of

FIGURE 13
Female genital anatomic structures. Clitoral excision refers to the cutting of the glans (which is the
distal part of the body of the clitoris) or the glans and part of the body. In all cases, part of the
clitoral body remains intact, with scarring overlying the remaining body. The bulbs and crura, two
other sexual erectile structures, have not been noted to be affected in FGM/C cases. Reprinted with
permission from Abdulcadir J, Botsikas D, Bolmont M, et al. Sexual anatomy and function in women
with and without genital mutilation: a cross-sectional study. J Sex Med. 2016;13(2):227–237 and Pauls
RN. Anatomy of the clitoris and the female sexual response. Clin Anat. 2015;28(3):376–384.
treatment in these cases, Medicaid is that there are currently few trained
should cover the defibulation. specialists with experience in
managing FGM/C, particularly in FIGURE 16
In all cases of defibulation, it is young children. Similarly, it may be Clinical approach to external female genital
advised that an experienced pediatric difficult to refer a girl or teenager to examination. (Reprinted with permission from
American Academy of Pediatrics. Visual Di-
gynecologist (for young children), a male provider, and much discussion agnosis of Child Abuse on CD-ROM. 3rd ed. Elk
gynecologist (for older children and and support will need to be provided Grove Village, IL: American Academy of Pediat-
teenagers), urologist, or to facilitate successful care. rics; 2008.)
urogynecologist be identified to Counseling patients who do not want
perform the procedure. One challenge to be defibulated, despite current visits, and it may be necessary to
complications, may be challenging dispel fears of loss of virginity in
given social and cultural pressures. cases of defibulation.67 Mental health
This counseling may take multiple and social issues may arise and need
to be addressed through counseling
and support. Multiple legal and
ethical issues may also arise in cases
in which a teenager desires
defibulation but she does not
want her parents to know because
of fear of stigma and/or refusal by
her parents (see The Law and FGM/C
in Minors in the United States, Ethical
Analysis, and Case 2 in the Appendix
FIGURE 14 for further information).
Normal prepubertal female anatomy. Labia
minora is often less well-developed than pic- For young children who are
tured in prepubertal girls.110 (Reprinted with FIGURE 15
permission from Graham EA. Ritual female Prepubertal female introitus. (Reprinted with defibulated, general anesthesia is
genital cutting [RFGC] PowerPoint slides. 2014. permission from American Academy of Pediat- recommended in all cases.
Available at: https://ethnomed.org/resource/ rics. Visual Diagnosis of Child Abuse on CD-
ritual-female-genital-cutting-rfgc-powerpoint- ROM. 3rd ed. Elk Grove Village, IL: American If a teenager is pregnant, defibulating
slides/. Accessed April 30, 2020.) Academy of Pediatrics; 2008.) her under spinal anesthesia during

TABLE 4 Resources
Title or Description Source
Care of Girls and Women Living with Female Genital Mutilation: A Clinical Handbook. WHO111
To find a regional FGM/C expert, please go to the US End FGM/C Network Web site https://endfgmnetwork.org/
Female Genital Mutilation/Cutting: Existing Federal Efforts to Increase Awareness Should Be US Government Accountability Office112
Improved
WHO Guidelines on the Management of Health Complications From Female Genital Mutilation WHO113
Eliminating Female Genital Mutilation: An Interagency Statement: OHCHR, UNAIDS, UNDP, UNECA, WHO2
UNESCO, UNFPA, UNHCR, UNIFEM, WHO
Female Genital Mutilation/cutting: A Statistical Overview and Exploration of the Dynamics of United Nations Children’s Fund16
Change
Female Genital Mutilation (FGM) Frequently Asked Questions United Nations Population Fund114
Background information and educational pamphlets in Amharic, Arabic, French, Somali, Swahili, US Citizenship and Immigration Services115
and Tigrinya
Guidelines for the US Domestic Medical Examination for Newly Arriving Refugees Centers for Disease Control and Prevention116
Immigrant Child Health Toolkit American Academy of Pediatrics117
Female Genital Mutilation. A Visual Reference and Learning Tool for Health Care Professionals Abdulcadir et al118; video available at https://www.youtube.
com/watch?v=XRid7jIUzMY
Defibulation: A Visual Reference and Learning Tool Abdulcadir et al68
Female Genital Mutilation/Cutting and Violence Against Women and Girls: Strengthening the Policy United Nations Entity for Gender Equality and the
Linkages Between Different Forms of Violence Empowerment of Women12
Overview: Female Genital Mutilation (FGM) National Health Service119
Female genital mutilation (FGM): Resources for Healthcare Staff National Health Service, Department of Health and Social
Care120
FGM: Mandatory Reporting in Healthcare National Health Service, Department of Health and Social
Care121
Canadian FGM/C statement Canadian Paediatric Society122
Australian FGM/C statement The Royal Australasian College of Physicians123,124
New Zealand FGM/C statement The FGM Education Programme124
the second trimester is advised. In WHO recommends local anesthesia as COMMUNITY ENGAGEMENT
countries where spinal anesthesia best practice, this recommendation is Within the United States, emerging
may not available, local anesthesia not based on strong evidence. Local evidence indicates
may be used, if necessary. This allows anesthesia is not recommended a misunderstanding and distrust
ample time for healing and will (unless in a country where spinal and among immigrant communities with
facilitate providing care during labor. general anesthesia may not be fears of deportation, criminalization,
However, some teenagers may available),68 because women may raids by Immigration and Customs
present late in the third trimester. report flashback memories from the Enforcement, and fear of being
They can still be defibulated up to 34 day when they were cut, as noted in reported to Child Protective Services
weeks’ gestation, which will allow for one case report.69 (CPS).70–74 Some health care and
the neo-vulva to heal adequately social service providers may also not
before labor. Otherwise, defibulating For type III FGM/C, timing and
understand the long-term physical
the patient preferably in the first complications of defibulation have
and mental health-related morbidity
stage of labor or when the baby is not been systematically studied in
associated with the practice of FGM/
crowning are options and are the prepubertal girls. For prepubertal
C.75 In addition, language barriers
routine approaches in some girls with complications, including
may complicate patient-provider
African countries, although these pain, obstruction of urinary stream,
communication and have been
approaches have not been and recurrent urinary tract infections,
demonstrated to negatively affect
systematically studied. Defibulation and teenagers with dysmenorrhea
health-seeking behavior and health
in the first stage of labor does related to FGM/C, it is important that
services use.30,76,77
facilitate pelvic examinations, the health care provider begin
catheterization, and general conversations with the parents and/ A grassroots community-based and
monitoring during labor while also or child regarding the need for community-led approach is essential
allowing for procedures on less defibulation to treat these medical when working with affected
edematous tissues and quicker complications and associated populations to ensure that policies,
delivery. If a teenager is not pregnant, morbidity as well as whether the girl preventive interventions, and
she can be defibulated under regional would benefit from mental health advocacy are all informed by the
or general anesthesia. Although the counseling. perspectives, experiences, and needs

TABLE 5 FGM/C Immediate and Long-Term Complications
Immediate Complications Long-term Complications
Category Description Category Description
41
Bleeding Hemorrhage Urinary Urethral strictures41
Anemia — Meatal obstruction41
Hypotension — Chronic urinary tract infection125
Hypovolemic shock — Pyelonephritis
Death41 — Meatitis
— — Urinary crystals
Infection Cellulitis Infection Chronic yeast infections
Abscess41 — Chronic bacterial vaginitis41
Fever41 — Herpes simplex virus
Pelvic inflammatory disease — Vulvar or periclitoral abscess41
Tetanus — No definitive data on risks for hepatitis B, hepatitis C, or HIV44,126
Gangrene — —
Septic shock — —
Poor healing41 — —
Oliguria Dehydration Scarring Fibrosis41
Urethral injury41 — Keloids41
Urethral edema41 — Partial fusion
Urinary retention41 — Complete fusion
— — Hematocolpos41
— — Inclusion or sebaceous cyst41
Fractures Clavicle Pain Neuromas
Femur — Chronic vaginal infections41
Humerus — Dyspareunia41
— — Vaginismus
— — Dysmenorrhea41
— Infertility Vaginal stenosis
— — Infibulated scar
— — Dyspareunia41
— — Apareunia
— Mental health Anxiety disordersa
— — Depressiona
— — Posttraumatic stress disordera
— — Somatisationa
—, not applicable.
a Large systematic studies are lacking. Some small studies have revealed an association between FGM/C and mental health diagnoses.49
of those directly affected by FGM/C.78 personnel. It is important to assess need to be explored and created. It is
There are varying approaches to whether local efforts already exist recommended that pediatric health
engage FGM/C-affected communities because it will be much easier to care professionals nurture
that need to be culturally and build and/or expand on these meaningful partnerships with FGM/
linguistically tailored on the basis of partnerships. If there are no C-affected communities to foster
availability of local expertise, preexisting relationships, new greater trust, open dialogue,
resources, infrastructure, and community-based partnerships may counseling, education, and
community outreach to enhance
culturally sensitive care for affected
TABLE 6 Obstetric Difficulties in Type III FGM/C populations and to prevent FGM/C
Obstetric Difficulties among female minors. In the past, the
Prolonged labor focus of outreach efforts has
Increased risk of perineal tears or episiotomy principally targeted women, who
Perineal wound infection have been at the forefront of the
Difficult episiotomy repairs perpetuation of FGM/C. However
Postpartum hemorrhage
men, as husbands, fathers, brothers,
Sepsis
Difficulty placing fetal scalp electrode, Foley catheter, or intrauterine pressure catheter sons, community leaders, and
Difficulty performing fetal scalp pH religious figures, also play a critical
Adapted from Nour NM. Female genital cutting: clinical and cultural guidelines. Obstet Gynecol Surv. 2004; role in changing social norms;
59(4):272–279. encouraging greater dialogue with

TABLE 7 Perinatal Complications of FGM/C medical interpreters, patient during their training. Hence, students,
Perinatal Complications navigators, community health including medical and nursing
Increased cesarean deliveries
workers, refugee resettlement students, residents, and fellows
Stillbirth agencies, and public health across various health, social
Low birth wt (data inconclusive)a departments. In addition, culturally science, and public health
Increase rates of infant resuscitation appropriate and language-congruent professions, should also be engaged
Adapted from Banks E, Meirik O, Farley T, resources, such as written in clinical care, counseling, education,
Akande O, Bathija H, Ali M; WHO Study Group on information on FGM/C, should be and community outreach on FGM/C
Female Genital Mutilation and Obstetric Out-
come. Female genital mutilation and obstetric made available in health care in such a way that is respectful of
outcome: WHO collaborative prospective study settings in the form of posters, patients, caregivers, and
in six African countries. Lancet. 2006; pamphlets, or leaflets placed in communities. Models of established
367(9525):1835–1841.
a One recent multicenter prospective study in private areas, such as women’s training guidelines and evidence-
the Gambia revealed no association between restrooms, and made available in based educational competencies
FGM/C and infants with low birth wt but relevant languages. specific to FGM/C are lacking across
a statistically significant increased risk of
perinatal death and need for infant re- all levels of health professions
Since 2015, mandatory reporting
suscitation (n = 1208).127 training. A proposed approach to
legislation in the United Kingdom has
instituting clinician competencies
come under increased scrutiny for the
includes convening
lack of consistent, reliable, high-
and engagement of their wives, a multidisciplinary team of experts
quality data as well as for the lack of
daughters, and sisters in health comprising key stakeholders from
a routine system of monitoring.80–83
services use; and supporting efforts clinical medicine, medical education,
Stigmatization of FGM/C-affected
toward eventual abandonment of the public health, and research. Their
communities and distrust of law
practice of FGM/C.77,79 Consequently, expertise in competency development
enforcement have resulted in
it is critically important to include processes as well as in FGM/C would
underreporting, along with a lack of
both men and women in strategies to address FGM/C-specific knowledge
professional awareness and
enhance health services use and and skills for clinical practice, patient
training.84 Within the context of
improve experiences with care while care and handling ethical
migration, the impact of
supporting community-wide FGM/C conundrums, communication skills,
acculturation, education, and length
prevention efforts. interprofessional collaboration
of stay on changing attitudes toward
(including partnering with
It is advisable that clinicians seek to the practice are critical
community activists), and prevention
engage within and across health care considerations when determining
efforts engaging individual families as
systems and multispecialty provider girls at risk for FGM/C85–87 The first
well as FGM/C-affected
dedicated multispecialty clinic in the
teams instead of staying within communities.32 Thereafter, evaluative
isolated profession-specific silos. United Kingdom for girls affected by
performance metrics could be used to
Such multidisciplinary teams may FGM/C and girls at risk with complex
assess whether clinician
comprise child abuse specialists, health needs uses a pediatric child
competencies and patient care
gynecologists, urologists, and general abuse expert, a pediatric adolescent
outcomes are being optimized.
surgeons in addition to nurses, social gynecologist with expertise in FGM/C,
Moreover, an integrated team-based
workers, teachers, psychologists, a child psychotherapist, and
approach to health care delivery may
counselors, case managers, certified a specialist nurse in pediatric and
more effectively address the
adolescent gynecology, along with
multidimensional facets of providing
interpreters.33 Referrals to this
holistic care, recognizing the
dedicated clinic are evaluated
intersection of ethnicity, migration,
promptly with genital as well as
sex, and gender, which underlies the
colposcopy examinations, followed by
social construct of FGM/C.88 Efforts
further testing, counseling, and
to directly engage FGM/C-affected
engagement of additional social and
communities to engender trust,
legal support services, as needed.
educate, promote continuity of care,
It is advised that attention also be and empower women and girls may
paid to ensuring that the next enhance their health literacy and self-
generation of health care providers efficacy in seeking care for FGM/
FIGURE 17 and scholars gain critical skills and C-related concerns, navigating the
Type IIb FGM/C with large cyst, Tanner stage 5 exposure to culturally appropriate health care system, and preventing
female patient (photo courtesy of N.N.). approaches to care for this population future FGM/C.

ETHICAL ANALYSIS also help persuade the family to forgo Outside the United States, many
Some have attempted to defend FGM/ FGM/C with their other children and countries have laws in place that
C by an appeal to cultural relativity, perhaps enable advocacy efforts with criminalize the practice of FGM/C
noting divergent mores and their local community as well as (see Table 2).
expectations in countries where it is extended family in their country of
frequently practiced.89 Such a defense origin.
Applicable US Federal and State
cannot overcome the fact that, as FGM/C performed by health care Laws
a rule, FGM/C may be physically and providers is not uncommon,
emotionally damaging, seriously representing 18% of cases from all The Federal Prohibition of Female
affecting a girl’s reproductive, sexual, countries with available data. In some Genital Mutilation Act of 1996 made
and mental health. It is intrinsically countries, health care providers are it illegal to perform FGM/C in the
a violation of the girl’s human rights, responsible for three-quarters of United States on children and
compromising her bodily integrity FGM/C procedures.93 If asked to teenagers younger than 18 years. The
without any medical benefit, without perform the procedure, even health act criminalizes circumcising,
her consent (or, frequently, even her care professionals who are morally excising, or infibulating “the whole or
assent). It represents an extreme case opposed to FGM/C might agree to do any part of the labia majora or labia
of sex discrimination through so out of a sense of cultural respect or minora or clitoris of another person
attempting to control a woman’s because they believe the alternative who has not attained the age of
sexuality.3 For these reasons, the (ie, the family seeking the procedure 18 years,” unless deemed medically
practice is condemned by a vast from traditional practitioners) to be necessary, and recognizes no religious
number of health care even worse. or cultural exemption for the practice
organizations.3,90,91 of any type of FGM/C. However,
By agreeing to perform the a recent federal district court
While condemning the practice itself, procedure, however, health care decision, United States v
as discussed previously, it is providers are granting it medical Nagarwala,21,94 has found the statute
important to show cultural sensitivity legitimacy, which not only undercuts unconstitutional. Despite this federal
to those who practiced FGM/C in the moral prohibition on the court decision invalidating the federal
their home countries. Some parents procedure but also contributes to its statute, at the time of this writing, 35
may not have felt they had a choice, spread and ongoing societal states have also enacted specific state
given prevailing cultural expectations, acceptance. As the WHO notes, “It can criminal statutes against FGM/C95,96
believing that FGM/C gave their also lead some health-care providers (see Table 8).
daughters the best chance of to develop a professional and
succeeding in a society where it was financial interest in upholding the Although FGM/C performed in
a prerequisite for marriage and practice,”15 and although the another country before US
acceptance.92 Other parents might immediate risks could be reduced if immigration is not reportable or
not have been fully aware of what the procedure were performed by prosecutable, transporting a child out
was going to happen to their children a trained professional, the risks of the of the United States for the purpose of
or believed it had some medical previously noted long-term FGM/C (so-called vacation cutting)
benefit. Thus, the fact that a girl complications remain. was criminalized in the Transport for
underwent this procedure is not Female Genital Mutilation Act of
a sign that her parents do not care 2013. When a child is at risk for
THE LAW AND FGM/C IN MINORS IN THE
about her or that they are more likely UNITED STATES FGM/C, including when traveling to
to engage in other forms of abuse. a country where FGM/C prevalence is
Within the United States, there are high and in cases in which the girl’s
So, although it is important to take several legal issues that confront mother and/or sisters have already
active steps to prevent children from health care providers in the context of had FGM/C performed before US
subsequently being subjected to a suspected FGM/C case, including immigration, it is recommended that
FGM/C, it is also important to treat the following: health care providers have an open
families whose children have already 1. applicable federal and state laws; and supportive conversation with the
undergone FGM/C with compassion. 2. consent and assent; parents regarding the significant
Experience suggests that building medical complications of FGM/C (see
3. reporting child protection and/or
rapport with parents increases the Complications and Management) and
criminal activity concerns;
probability that they will give legal implications to parents or other
permission for remedial 4. confidentiality; and caregivers if they have FGM/C
interventions. Such an approach may 5. documentation. performed on their child.

18
TABLE 8 FGM/C Laws, by State (as of July 12, 2019)
State Applicable Law Only Applies to Vacation Cutting Duty To Report Cultural and Ritual Parent or Guardian and Sentence
Minors (,18 Provision (Bans Travel (Including FGM as Reasons and/or Circumciser Subject
Unless Outside State Child Abuse) Consent Not to Prosecution
Otherwise for FGM/C) a Defense
Specified)
Arkansas A.C.A. 5-14-135, 12-18-103, 16- X X X X X Imprisonment 3–10 y
118-116, 17-80-121, 20-82-
101, 20-82-102
Arizona A.R.S. xx 12-513, 13-705, 13- X X X — — Imprisonment 5.25–35 y and fine up to
1214, 13-3620, $25 000
Californiaa Cal. Pen. Code x 273a, 273.4 X — — — X Imprisonment 1–6 y
Coloradob Col. Rev. Stat. x 18-6-401 ,16 — — X X Imprisonment minimum 4 y
Delaware Del. Code Tit. 11, x 780 X — — X X Imprisonment up to 5 y
Florida Fla. Stat. x 794.08 X X — X X Imprisonment up to 15 y and/or fine up to
$10 000
Georgiac O.C.G.A. x 16-5-27 X X — X X Imprisonment 5–20 y
Idaho I.C 18-1506B, I.C. 19-402 X — — X — Imprisonment up to life
Illinois 720 Ill. Comp. Stat. 5/12-34; — — X X X Imprisonment 6–30 y
325 Ill. Comp. Stat. 5/3, 5/4
Iowa I.C.A. 708.16 X X X X — Imprisonment for up to 5 y and fine of
$750–$7500
Kansas K.S.A. x 21-5431 X X — X X Imprisonment 89–100 mo
Louisiana La. R.S. 14:43.4 X X — X X Imprisonment up to 15 y
Maryland Md. Code Health-Gen. x 20-601, X — — X X Imprisonment up to 5 y and/or fine up to
602 $5000
Michigan 1931 PA 328 x 136 1978 PA 368 X X — X X Imprisonment up to 15 y
x 9159
Minnesota Minn. Stat. x 144.3872, — — — X — Imprisonment up to 5 y and/or fine to $10 000
609.2245
Missouri Mo. Rev. Stat. x 568.065 Under 17 — — X X Imprisonment 5–15 y
Nevada Nev. Rev. Stat. x 200.5083 X X — X X Imprisonment 2–10 y and/or fine up to
$10 000
New N.H. Rev State.x 632-A:10-d X — X X — Imprisonment up to 7 y
Hampshire
New Jersey N.J. Stat. x 2C:24-10 X X — X X Imprisonment 3–5 y

New York N.Y. Penal Law x 130.85; N.Y. X — — X X Imprisonment up to 4 y
Public Health Law x 207(k)
North Dakota N.D. Cent. Code x 12.1-36-01 X — — X — Imprisonment up to 5 y and/or fine up to
$10 000
Ohio OH ST xx 2903.32, 2929.14, X — X X — Imprisonment 2–8 y, fine up to $40 000, and/
2929. 18 or a fine up to $15 000 and an additional
fine up to $25 000
Oklahoma 21 Okl. St. x 760 — — X — Imprisonment 3 y to life and/or fine up to
$20 000
Oregon Or. Rev. Stat. x 163.207 X — X X Imprisonment up to 10 y
Pennsylvania 18 Pa. C.S.A. 3132 X X X X X Imprisonment for .10 y
Rhode Islandd R.I. Gen. Laws x 11-5-2 — — — — — Imprisonment up to 20 y
FROM THE AMERICAN ACADEMY OF PEDIATRICS

TABLE 8 Continued
State Applicable Law Only Applies to Vacation Cutting Duty To Report Cultural and Ritual Parent or Guardian and Sentence
Minors (,18 Provision (Bans Travel (Including FGM as Reasons and/or Circumciser Subject
Unless Outside State Child Abuse) Consent Not to Prosecution
Otherwise for FGM/C) a Defense
Specified)
South Code 1976 16-3-2210-2240 X X X X X Imprisonment up to 20 y and/or fine up to
Carolina $20 000
South Dakota S.D.C.L. xx 22-18-37, 22-18-38, X X — X X Imprisonment up to 10 y and fine up to
22-18-39 $20 000
Tennessee Tenn. Code x 39-13-110, 38-1- — — X X — Imprisonment 2–12 y and/or fine up to $5000
101
Texas Tex. Health & Safety Code x X X — X X Imprisonment 6 mo to 2 y and/or fine up to
167.001 $10 000
PEDIATRICS Volume 146, number 2, August 2020

Utah U.C.A. 1953 76-5-701, 76-5-702, X X X X X Imprisonment up to 5 y and/or fine up to
76-5-703, 76-5-704 $5000
Virginia Va. Code xx 8.01-42.5, 18.2-51.7 X X — — X Imprisonment up to life and/or fine up to
$100 000
West Virginia W. Va. Code x 61-8D-3A X — — X X Imprisonment 2–10 years and fine
$1000–5000
Wisconsin Wis. Stat. x 146.35 X — — X — Imprisonment 6 y and/or fine up to $10 000
States with no existing FGM/C laws (as of July 12, 2019): Alabama, Alaska, Connecticut, Hawaii, Indiana, Kentucky, Maine, Massachusetts, Mississippi, Montana, Nebraska, New Mexico, North Carolina, Vermont, Washington, and Wyoming. Adapted
from Equality Now. Female genital mutilation in the United States. Available at: https://www.equalitynow.org/factsheets. Accessed May 25, 2018 and from Mishori R, Warren N, Reingold R. Female genital mutilation or cutting. Am Fam Physician. 2018;
97(1):52A. X, existing law; —, no current legislation addressing this issue.
a California: enhanced penalty for FGM/C under “Abandonment and Neglect of Children” (Penal Code).
b Colorado: within child abuse law and one of few states where doctor-patient and husband-wife privileges are inapplicable in prosecutions for FGM/C.
c Georgia: one of few states where husband-wife and other statutory privileges are inapplicable in prosecutions for FGM.
d Rhode Island: within assault statute.

Consent and Assent
statute of some states.
intellectual capacity.100
may consent to that specific
notable exceptions. The first
involves the so-called “minor
such as reasoning ability and

transmitted infections, mental
related to reproductive health
a minor patient who is legally

Before discussing consent and
The second exception involves

fall under the minor treatment
Again, state laws vary as to the

assent issues as they pertain to
outside the scope of the statute.

consent to treatment of sexually
children generally lack sufficient
state, such as getting married or

prenatal care, and pregnancy). If
providers not assume a minor is

a specific action, which varies by
minor treatment statute, a minor
of its complications could impact
be deemed sufficiently mature to

deemed a “mature minor”99 after
the legal authorization to provide
such as being self-supporting and
or having obtained one’s diploma.

true informed consent, with three
emancipated. Emancipation98 may

treatment qualifies under a state’s
(including contraception, abortion,
FGM/C, it is appropriate to review
The third exception involves being
being assessed for relevant factors

reproductive health and, thus, may
minor fulfills specific requirements
It is recommended that health care

illness, substance abuse, or matters
either being enrolled in high school

these concepts. Informed consent is
precise requirements for a minor to

decision-making capacity to provide
treatment but not to others that fall
be automatically conferred by taking

state but generally permit minors to
medical care to an individual. Minor
make her own health care decisions.

serving in the active duty military, or
19
may be declared by a court after the
Evaluation for FGM/C and treatment
treatment statutes,”97 which vary by
mature unless provided with clear may be wise to consult with a child FGM/C that occurred before
court documentation. Unlike the abuse pediatrician. immigration to the United States does
minor treatment statutes, not meet the legal requirement for
emancipated and mature minors are Even if parental permission is not breaching confidentiality by reporting
granted the right to make all their required for the reasons noted here, if to state agencies. Furthermore,
own medical decisions, which would the patient is old enough to provide reporting past or current FGM/C runs
include not only evaluation of FGM/C assent, it is advisable to obtain this the risk of damaging not only the
but also interventions to treat it and before proceeding. Additionally, therapeutic relationship with an
its complications. maintaining open lines of individual patient and her family but
communication with the patient’s also with the immigrant community
Outside these specific exceptions, parents is helpful, which may include to which that family may belong. If
parents are tasked with making informing them of what is being health care providers are perceived
nonemergency medical decisions for performed and why. not only as judgmental (ie, culturally
their minor children, which is termed
insensitive) but also as agents of the
“parental permission.” But even if The other context in which parental
state, families may be less likely to
a child is incapable of informed permission is not required is
seek out needed medical care for
consent, she still has a role in medical emergent situations such as active
their children. The opportunity for
decision-making. It is recognized that hemorrhage or imminent delivery
advocacy to prevent future potential
a child’s decisional capacity evolves with infibulation. If the parents are
instances of FGM/C may also be lost.
over time, and so “assent” refers to unavailable to provide permission,
a pediatric patient’s agreement to consent may be presumed if three Most states also require a report to be
evaluation and treatment to the conditions hold: made if there exists reasonable cause
degree that she is able to comprehend to believe that child abuse may occur
1. there is a serious and immediate
what is being proposed. This involves in the future. Immediate or imminent
threat to life or health;
developmentally appropriate risk warrants notification of local law
awareness of the nature of the 2. there is a need for urgent enforcement authorities as well. If
condition, appreciation of what to intervention (delay in care is not a child experienced FGM/C before
expect with tests or treatments, and safe); and immigration to the United States,
being free of inappropriate 3. the health care provider which is not reportable, health care
pressure.101 In nonemergency administers only care and providers might, in some cases, be
situations, the older child and treatment of emergency conditions concerned for other female children
adolescent should give assent to that pose an immediate threat to in the home who might subsequently
evaluation and/or treatment. the child.103 be subjected to FGM/C. It is
important that these situations be
There are two other situations in In such situations in which the evaluated individually and on the
which parental permission is not parents are available yet withhold basis of a culturally sensitive
required for the evaluation and permission, evaluation and treatment discussion with the child’s primary
treatment of a child. The first is when may proceed on the basis of the care givers and child, if
abuse is suspected, such as FGM/C presumption of medical neglect and developmentally appropriate. It is
that occurred in the United States, or the duty of the state to protect the advisable that the dialogue include
as vacation cutting after immigration patient from harm (the doctrine of a review of health risks and
to the United States. Most states grant parens patriae). complications as well as legal
immunity to a provider who assists or
repercussions of FGM/C. As needed, it
participates in an investigation of
Reporting Child Abuse is important that cultural concerns be
allegation of maltreatment (ie,
addressed and that community
conducts a nonemergency evaluation Health care providers in the United
organizations be engaged to enhance
for abuse, including the physical States are mandated reporters of
parental understanding. This dialogue
examination, and taking necessary suspected child maltreatment, which
should be recorded in the child’s
photographs or radiographs and includes FGM/C that occurred in the
medical record.
performing medically relevant tests) United States or as vacation cutting
from any civil or criminal liability outside the United States after this After such education and dialogue, if
related to that participation.102 It is practice was criminalized in 2013. a health care provider has reasonable
prudent for health care professionals Physical examination findings cause to believe that a child may
to be knowledgeable of their state- suggestive of FGM/C, with previous subsequently be subjected to FGM/C,
specific child maltreatment legislation documentation of normal genitalia, CPS should be notified. As mentioned
(see Table 8). If questions arise, it should prompt reporting to CPS. previously, what constitutes

reasonable cause to believe is Appendix). Laws and regulations external genital examination and,
a nuanced and case-specific question. regarding child abuse reporting are particularly, photography of a girl
However, it is advised that health care different in other countries. It is or teenager may be difficult to
providers remember that the prudent for health care providers to explain to families from other
threshold for reporting maltreatment be cognizant of their country-specific cultures, photographs may be
does not require incontrovertible requirements. reserved for those times when
certainty, just a reasonable suspicion. there are concerns that suspected
Studies have revealed that Confidentiality FGM/C constitutes child abuse.
pediatricians have multiple reasons In the adolescent patient with past, 5. Report impressions objectively,
for either delaying or not reporting current, or future FGM/C concerns, it comprehensively, and in as simple
suspected maltreatment (ie, mistrust is important for health care providers language as possible. When
of the child welfare investigative to have a comprehensive discussion applicable, report alternative
system and familiarity with the with the patient about the diagnoses considered relevant to
family, to name a few) and that expectations and limitations of the findings and impression, such
physicians sometimes require confidentiality. FGM/C that occurred as labial adhesions or normal
inordinately high degrees of certainty in the United States or as vacation anatomic variants. In cases in
before reporting suspected cutting after it was criminalized in which either identification of the
maltreatment.104 2013 is subject to federal and state diagnosis of FGM/C is not clear, it
reporting laws. is strongly recommended to
If a clinician is uncertain whether the
fact pattern of a particular case consult a health care provider who
Documentation
reaches the threshold of reasonable is well versed in diagnosis of FGM/
cause to believe, it is appropriate to Objective and thorough C in prepubertal or pubertal girls,
consult a child abuse pediatrician. documentation is extremely depending on the case, given that
Expressed intention to engage in important in potential (and actual) type I and II FGM/C may be
FGM/C, either in the United States or child maltreatment circumstances. difficult to diagnose (see Table 4).
abroad, should prompt a report to The following recommendations (Do’s Such consultation is highly
CPS if the child’s parent or caregiver and Don’t’s) may assist health care recommended before reporting to
cannot be dissuaded. providers in ensuring appropriate CPS, especially if the family is
clinical documentation in the FGM/C amenable.
To avoid stereotyping, as well as scenario. 6. If FGM/C has been recently
harm to the therapeutic relationship,
performed in the United States, or
it is important to avoid making Do’s
abroad and after initial
assumptions and to be attentive to 1. Document in the medical record immigration, create the CPS
implicit biases. Many families who the particulars regarding informed report in a timely fashion,
originate from countries with high consent or permission (ie, who and as soon after evaluation
prevalence of FGM/C may travel back gave it, when it was given, for as possible.
to the country of origin for many what purpose, etc).
reasons wholly unrelated to FGM/C. 7. Document (in reasonable detail),
2. For children able to assent, obtain where appropriate, all
Although some communities accept
their assent before proceeding consultations with colleagues,
FGM/C as a sign of cultural identity or
with examination of external patients and/or parents, and
enhancing marriageability, anecdotal
genitalia. multidisciplinary partners.
expert experience suggests that many
mothers from high-prevalence 3. Carefully and objectively
countries do not want to subject their document any examination
limitations or mishaps in the Don’t’s
daughters to FGM/C. This may be
particularly true when the mother record. 1. Insert language into the record or
herself has suffered medical 4. Describe physical findings in a report that is inflammatory,
complications, although this situation detail. When possible, and after superfluous, or highly subjective
has not been systematically studied. attaining appropriate consent, (ie, “profoundly,” “faulty,” “sloppy,”
Recognizing this, it is appropriate to photo-document abnormal genital “terrible,” “negligent,” “careless,”
engage in an open and supportive findings and maintain them in “horrible,” “uncaring,” “pathetic,”
discussion with the family about their a secure fashion in compliance “horrific,” “barbaric,” etc).
beliefs about FGM/C. This may with privacy rules of the Health 2. State conclusions that are not
involve inquiring as to the family’s Insurance Portability and supported by specific facts or by
plans for their daughter (see Accountability Act. Given that the medical literature, especially if

the identification or diagnosis of however, FGM/C will only be addressing pediatric FGM/C (see
FGM/C is unclear or uncertain. identified if primary care providers Table 4).
3. Record information in the record become adept at performing external 6. If genital examination findings
or a report that has primarily legal genital examinations on all children at are equivocal for the presence of
implications and minimal or no every health supervision FGM/C and risk factors for FGM/
patient care value. appointment. It is recommended that C are present, a specialist trained
health care providers who are not in identification of FGM/C should
Legal Right to Asylum Protection in comfortable with making an FGM/C be consulted (see Table 4).
the United States and FGM/C diagnosis or discussing treatment
7. The management of FGM/C
options consult a specialist who is
FGM/C presents one other legal should include complete
trained in addressing pediatric FGM/
consideration for clinicians, that of US documentation of clinical
C. Open and culturally sensitive
asylum protection. US asylum findings and the use of ICD-10
discussions among health care
protection may be granted to coding.
providers, parents, and children
someone who has left their native 8. Health care providers should
regarding FGM/C is of utmost
country because of persecution or recommend defibulation for all
importance in addressing FGM/C that
fear that they will suffer from girls and teenagers with type III
has already occurred as well as in
persecution,105 including because of FGM/C, particularly when
preventing future FGM/C from
membership in a particular social complications are currently
occurring.
group, in this case being female and present.
living in a country where FGM/C is
9. In all cases in which defibulation
practiced. To be granted asylum, RECOMMENDATIONS is recommended, an experienced
a person must either be
1. Health care providers should not pediatric gynecologist (for young
physically present in the United
perform any type of FGM/C on children), gynecologist (for older
States or at a port of entry to the
female infants, girls, or teenagers. children and teenagers),
United States, and certain other
2. Health care providers caring for urologist, or urogynecologist
conditions must be met through
girls at risk for FGM/C should should be identified to perform
a formal process with US Citizenship
actively counsel families against the procedure.
and Immigration Services.
performing FGM/C, including 10. Standardized training related to
The 1996 US ruling, the Matter of when families travel to countries the identification, treatment,
Kasinga, established the right of where FGM/C is practiced. management, and culturally
asylum protection for women and appropriate communication
3. With consent and/or assent of
children potentially facing FGM/C.106 approaches needs to be
the guardian and/or child
However, the scenarios of past FGM/C developed and provided to
documented in the patient’s
and parents seeking asylum on the health care providers who
chart, all children should have
basis that their daughters would be care for FGM/C-affected
external genitalia examined at all
subjected to FGM/C if they returned communities.
health supervision examinations,
to their home country are more
including the identification of the 11. If FGM/C is suspected to have
nuanced and case specific. It is
prepuce, clitoris, and labia occurred in the United States, or
prudent for clinicians to recognize
minora and majora. as vacation cutting after
this potential protection for their
4. For children with risk factors for immigration to the United States,
patients and to direct families to an
FGM/C, it is recommended that the child should be evaluated for
immigration law attorney if such
clinical assessment of FGM/C potential abuse. Expressed
issues arise.
status be integrated into routine intention to engage in FGM/C,
pediatric care and that a history either in the United States or
CONCLUSIONS of FGM/C before US immigration abroad, should also prompt
be documented in the health a report to CPS if the child’s
FGM/C in children is a complex issue
record. parent or caregiver cannot be
with potential medical, mental health,
dissuaded.
and legal ramifications. It has no 5. It is recommended that health
clinical benefits and is associated care providers who are not
with significant morbidity and comfortable with making an ACKNOWLEDGMENT
mortality. Health care providers FGM/C diagnosis or discussing We acknowledge the contribution of
caring for diverse patient populations treatment options consult Zeinab Eyega (founder and executive
may identify FGM/C in their patients; a specialist who is trained in director, Sauti Yetu Center for African

Women and Families) for her expert J.Y., General Pediatrician what she learned and thought. It is
analysis of the case examples Some girls do not recall undergoing essential to determine the teenager’s
presented in the Appendix. FGM/C, particularly if it occurred at support network, whether peers,
a young age. Expert opinion suggests a teacher, or a counselor, that can
that some parents do not inform their provide regular guidance and help as
APPENDIX: CASE EXAMPLES AND daughters of having been cut. In this needed. The teenager’s boyfriend may
EXPERT ANALYSIS case, it is important to explain be from within or outside of her
physical findings to the patient and cultural group. Over time, it is
An example of an approach when
use diagrams, such as the one in Fig 4. important to discuss with the
discussing FGM/C with the child or
She will need to be supported in teenager whether she is concerned
teenager’s mother may include
understanding why she was cut, and about her appearance because of her
statements such as the following:
it is recommended that the care FGM/C. If she does not have any
I am learning about cultural practices in your current health issues or concerns and
country and understand that female genital provider explore how and if she
would like to discuss her FGM/C with there are no medical problems, the
cutting is done in your country. Were you cut as
a child? Were your daughters cut while you were her mother, either with the medical discussion may be left and revisited if
still living there? The reason I ask is that I am provider present or not. If the patient concerns arise.
a physician and female genital cutting may have
is contemplating a sexual
severe medical complications, including recurrent S.K.N., Child Abuse and Legal Expert
urinary tract infections, painful menstruation, relationship, she may be concerned
and severe scarring blocking the flow of urine about her genitalia appearing An honest but respectful discussion
and menstrual blood. I want to make sure that different. She may also have needs to occur, exploring the family’s
you and your daughters are not having these questions about sexual function. current beliefs regarding FGM/C,
issues because they can be treated. I also want to
These questions may be addressed education about medical
make sure that you understand that it is illegal to
either at this visit or at follow-up complications and/or risks, and
have a girl cut once she is living in the United
States. This includes not sending her to another visits over time. Referral for culturally education about US laws prohibiting
country to have her cut once she has been living appropriate mental health supports the practice. It is important to
in the United States. may also be warranted in this case. If remember to obtain more history
this patient has female siblings, it is about when the family came to the
Consider discussing FGM/C with the recommended that they also have United States and whether there are
mother at the end of the visit after head-to-toe physical examinations, other female siblings who may be at
obtaining a history and performing including external genitalia, and risk. A private discussion with the
the physical examination. Introducing physical findings should be mother is recommended to learn of
a conversation regarding FGM/C early documented. It is recommended that when and where the FGM/C occurred.
in a visit may serve as a barrier to a culturally sensitive discussion occur If it occurred outside US jurisdiction,
establishing trust and rapport. with the mother and father regarding FGM/C is not grounds for reporting,
the medical issues associated with but the safety of other younger
FGM/C and that FGM/C performed in female siblings in the house at future
the United States or as vacation risk should be considered.
CASE 1
cutting is illegal. These discussions
The patient is a 16-year-old teenaged R.C.M., Medical Ethics Expert
should be documented in the
refugee born in Mali and living in patient’s chart, and the diagnosis of The important ethical issues
Mauritania before US arrival. She has FGM/C should be included in the (including the patient’s right to
established care with her primary patient’s past medical history as understand her condition and the
care pediatrician, who explains that having occurred before arrival in the obligation to protect female siblings
she needs to perform a full physical United States. who might be at risk) are well
examination, including examination addressed in the preceding
of her external genitalia. The teenager commentaries.
assents to the examination and is Zeinab Eyega, Founder and Executive
found to have type IIb FGM/C. The Director, Sauti Yetu Center for
girl does not know that she has been African Women and Families CASE 2
cut and has no recollection of the The pediatrician should ask how the The patient is a 17-year-old Sudanese
procedure having occurred. She is patient feels about her diagnosis of girl with type III FGM/C performed
confused and does not understand FGM/C, if the teenager has questions before US immigration who has
what her FGM/C means for her and about the practice, and if she has ever severe dysmenorrhea from partial
how she will discuss this with her heard about FGM/C at school or obstruction of menstrual flow. She
parents and boyfriend. through friends or family and if so, wants to undergo defibulation. The

teenager gives permission for the a meeting with both the teenager and risk of morbidity or mortality), her
pediatrician to discuss the issue with parents present. It is important to parents’ unwillingness to give
her parents and the medical learn from the parents if they have permission to defibulation could
recommendation to undergo noted the medical issues, including represent medical neglect. Even if her
defibulation because of medical pain, that their daughter has had condition is not an emergency, the
complications. The parents are very because of her type III FGM/C and patient could be declared by the court
concerned about defibulation and that the recommended treatment is to be a mature minor, depending on
reluctant to give permission. defibulation. Some parents (most the laws of her state,99 and could thus
likely the mother) may be concerned have the legal right to consent to the
J.Y., General Pediatrician that if their daughter is defibulated, procedure herself.
With the teenager’s consent, it is the procedure would affect her
recommended to arrange a meeting virginity. It is important to address
CASE 3
with the parents to discuss the this concern to ensure that the
complications their daughter is teenager continues to have support A 10-year-old girl born in the United
having from her FGM/C, including from her parents after defibulation so States in 2008 to Ethiopian refugee
severe pain with menstruation from that she does not feel isolated from parents presents for well-child care.
partial obstruction of menstrual flow. her parents and other family She had a documented normal
Consider initiating the conversation members, both of which could physical examination, with normal
with the parents by asking what their negatively affect her emotional well- female genitalia, at her newborn visit.
understanding of FGM/C is and being. The parents may need time to Well-child care examinations at 4, 6,
exploring why it is or is not important process the information, and another and 8 years of age occurred with the
to them. It is recommended to show appointment should be offered as genital examination marked as
diagrams of the teenager’s anatomy well as the option to meet with “deferred” at each visit. Of note, the
and explain the issues that the a counselor to discuss the issue with girl traveled to Ethiopia in 2012 to
infibulation is causing as well as her the counselor. visit relatives with her mom. A full
risk for future complications, including physical examination, including
possible issues with scarring, chronic S.K.N., Child Abuse and Legal Expert, external genitalia, reveals type Ib
pain, and infertility. Several meetings and R.C.M, Medical Ethics Expert FGM/C. Once the child is dressed, the
may be required to review the medical mother is separately asked if her child
This scenario is nuanced and could
issues and the recommendation to had FGM/C performed. She denies
constitute medical neglect by the
defibulate the teenager to relieve any knowledge of her child being cut
parents (depending on the severity of
symptoms, both short- and long-term. abroad.
symptoms and degree of obstruction).
As with case 1, if there are other If possible, the general pediatrician
female siblings in the home, it is
J.Y., General Pediatrician
should consult a child abuse
recommended to make arrangements pediatrician because they will know It is important to ask the 10-year-old
to perform a full physical examination the local CPS personnel and whether she recalls having been cut.
on the other female siblings, including procedures well and may be able to If she does remember being cut, she
visualization of the external genitalia, provide an idea of their potential will be able to provide more
and findings should be clearly response. Furthermore, the general information regarding when and
documented in the chart. A frank but pediatrician should have an honest where it happened as well as who
culturally sensitive discussion should and respectful discussion with was involved. If she is unable to
occur with the parents, explaining parents about the teenager’s provide any information about the
medical complications and the medical need for defibulation and cutting, it is important to document
illegality of future FGM/C documented about their failure to consent possibly this information in her medical chart.
in the chart as well as documentation requiring a report to CPS for Although more likely the FGM/C
of FGM/C having occurred overseas, intervention. occurred overseas on her visit with
before immigration, in the past relatives, it is theoretically possible
medical history. Although 18 years is the age of that she had FGM/C performed in the
majority in nearly every state, some United States. In this case, it would be
Zeinab Eyega, Founder and Executive younger patients may possess reasonable to consult with a child
Director, Sauti Yetu Center for sufficient decision-making capacity to abuse specialist in your state. As with
African Women and Families make informed and voluntary health cases 1 and 2, if there are other
If the teenager consents to allowing care decisions.101 If her condition female siblings in the house, these
a discussion with her parents, the represents a current threat to her children should be examined, and
pediatrician should facilitate health (in terms of pain, suffering, or physical findings and medical and

legal education regarding FGM/C CASE 4 S.K.N., Child Abuse and Legal Expert
should be clearly documented in the The patient is a 5-year-old female A thorough psychosocial history
patient’s health record. refugee from Somalia via a Kenyan should be obtained to assess the
refugee camp who had type IIIb FGM/C social dynamics of the family. An
Zeinab Eyega, Founder and Executive performed 6 months before US honest and respectful discussion
Director, Sauti Yetu Center for immigration. The child has her urethral should occur that, as in case 2, should
African Women and Families opening covered by labia minora, and highlight the possible need to report
urinary stream occurs through a 2 3 to CPS if permission is denied for the
The pediatrician should start by
2 mm opening in the otherwise sealed health and safety of the child. Again, if
speaking with the parents separately
labia minora. The patient has reported available, consultation with a child
from the child and explaining that her
delay in bladder emptying and pain, abuse pediatrician is advised because
examination reveals FGM/C that was
per maternal report. She has no report that individual will know the local
performed after she was born in the
of past urinary tract infections, CPS personnel, procedures, and
United States. It is important to show
prolonged fever, or vomiting. responses well.
diagrams revealing the difference
between a cut and uncut child so that R.C.M., Medical Ethics Expert
J.Y., General Pediatrician
the parents understand. Ask
A supportive discussion should occur The patient has a condition that leads
questions about other family
with the parents regarding the pain and to pain and impaired urinary outflow.
members and if they have also had
medical complications associated with Irrespective of the cause, this needs to
FGM/C. In some cases, biological
the child’s type III FGM/C, including be addressed. The clinical situation
parents may not be involved in the
risk for recurrent urinary tract should be explained to the parents as
decision to circumcise their daughter
infections and renal scarring. Diagrams well as recommendations made to treat
and may not know that she was cut.
should be used to demonstrate the the urinary retention and pain. Parental
In such cases, a respected elder in the
issues associated with acute urinary refusal of the intervention to address
community, such as a grandmother or
obstruction. This discussion may take these problems suggests they are not
aunt, may make this decision for the
several visits, with strict return acting in the best interest of the child.
girl and have her cut.
precautions reviewed each time, LEAD AUTHORS
including the need to bring the child
S.K.N., Child Abuse and Legal Expert Janine Young, MD, FAAP
immediately for medical evaluation if the Nawal M. Nour, MD, MPH, FACOG
Although this scenario may not be following conditions are present: fever, Robert C. Macauley, MD, FAAP
prosecutable as vacation cutting or vomiting, dysuria, or urgency to urinate, Sandeep K. Narang, MD, JD, FAAP
reportable, as in case 1, it is advisable frequency of urination, and/or the
inability to pass urine. With consent of CONTRIBUTING AUTHOR
to gather more psychosocial history
about the family makeup and the the parents, a trusted leader in the Crista Johnson-Agbakwu, MD, MSc, FACOG
family’s current beliefs about FGM/C. Somali community may need to be called
SECTION ON GLOBAL HEALTH EXECUTIVE
on to help support the parents in
COMMITTEE, 2019–2020
deciding to allow their child to undergo
R.C.M., Medical Ethics Expert defibulation. Patrick T. McGann, MD, MS, FAAP,
Chairperson
Although the patient is unable to Chiquita Palha De Sousa, MD, MPH, FAAP
provide informed consent for Zeinab Eyega, Founder and Executive Heather Haq, MD, MHS, FAAP
evaluation and treatment, she is Director, Sauti Yetu Center for Alcy R. Torres, MD, FAAP
developing the capacity for assent African Women and Families Ifelayo P. Ojo, MBBS, MPH, FAAP
Nicole E. St. Clair, MD, FAAP
and thus is entitled to an explanation It is important to use diagrams to Parminder Suchdev, MD, MPH, FAAP,
of her condition, provided in review the physical findings of female Immediate Past Chairperson
a nonjudgmental and genital cutting with the parents and
developmentally appropriate fashion, to explain why the child is having FORMER MEMBERS OF THE SECTION
with her questions welcomed and problems emptying her bladder and Linda D. Arnold, MD, FAAP
consistent promises of ongoing has pain. Explain that it is Kevin J. Chan, MD, MPH, FAAP
support. The pediatrician should also Cynthia R. Howard, MD, MPH, FAAP
recommended to have the child
Katherine Yun, MD, MHS, FAAP
strive to establish rapport with the defibulated and that this will not
family, who may be denying affect her virginity or her ability in COMMITTEE ON BIOETHICS, 2019–2020
knowledge because of fear of the United States to marry later in Robert Conover Macauley, MD, MDiv, FAAP,
repercussions or may truly be life. If there are other daughters, they Chairperson
unaware. should also be examined. Ratna Basak, MD, FAAP

Gina Marie Geis, MD, FAAP James P. Scibilia, MD, FAAP Florence Rivera, MPH
Naomi Tricot Laventhal, MD, FAAP, Section Erick Amick, MPH, MA
Member – Section on Bioethics LIAISONS
Douglas John Opel, MD, MPH, FAAP ACKNOWLEDGMENTS
Mary Lynn Dell, MD, DMin, Committee on
Mindy B. Statter, MD, FAAP
Bioethics Liaison – American Academy of The authors acknowledge the
Child and Adolescent contribution of Zeinab Eyega,
COMMITTEE ON MEDICAL LIABILITY AND
Douglas Scott Diekema, MD, MPH, FAAP,
RISK MANAGEMENT, 2019–2020 Founder and Executive Director, Sauti
Committee on Bioethics Liaison – American
Jonathan M. Fanaroff, MD, JD, FAAP, Board of Pediatrics Yetu, Center for African Women and
Chairperson David Shalowitz, MD, Committee on Families, for her expert analysis of the
Robin L. Altman, MD, FAAP Bioethics Liaison – American College of case examples presented in the
Steven A. Bondi, JD, MD, FAAP Obstetricians and Gynecologists Appendix.
Sandeep K. Narang, MD, JD, FAAP
Richard L. Oken, MD, FAAP TECHNICAL CONSULTANT
John W. Rusher, MD, JD, FAAP
Jasmine Abdulcadir, MD, FMH
Karen A. Santucci, MD, FAAP
James P. Scibilia, MD, FAAP
ABBREVIATIONS
LEGAL CONSULTANT
Susan M. Scott, MD, JD, FAAP CPS: child protective services
Laura J. Sigman, MD, JD, FAAP Nanette Elster, JD, MPH, Committee on
FGM/C: female genital mutilation
Willa Michelle Terry, MD, FAAP Bioethics Legal Consultant
or cutting
Robert Turbow, MD, JD, FAAP
STAFF ICD-10: International Classification
FORMER MEMBERS OF THE COMMITTEE Terrell Carter, MHS of Diseases, 10th Revision
Robin L. Altman, MD, FAAP Sherri L. Smith, MPH WHO: World Health Organization
Sandeep K. Narang, MD, JD, FAAP Julie Kersten Ake
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements
with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
DOI: https://doi.org/10.1542/peds.2020-1012
Address correspondence to Janine Young, MD, FAAP. E-mail: janine.young@dhha.org
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2020 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: Dr Johnson-Agbakwu has a grant relationship with Arizona State University from the 2018 copyright of “Female Genital Mutilation/Cutting
(FGM/C): A Visual Reference and Learning Tool for Health Care Professionals.”
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: Dr Johnson-Agbakwu has a grant relationship with Arizona State University from the 2018 copyright of “Female Genital
Mutilation/Cutting (FGM/C): A Visual Reference and Learning Tool for Health Care Professionals.”
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Diagnosis, Management, and Treatment of Female Genital Mutilation or Cutting
in Girls
Janine Young, Nawal M. Nour, Robert C. Macauley, Sandeep K. Narang, Crista
Johnson-Agbakwu, SECTION ON GLOBAL HEALTH, COMMITTEE ON
MEDICAL LIABILITY AND RISK MANAGEMENT and COMMITTEE ON
BIOETHICS
Pediatrics 2020;146;
DOI: 10.1542/peds.2020-1012 originally published online July 27, 2020;
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/146/2/e20201012
References This article cites 68 articles, 14 of which you can access for free at:
http://pediatrics.aappublications.org/content/146/2/e20201012#BIBL
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Diagnosis, Management, and Treatment of Female Genital Mutilation or Cutting
in Girls
Janine Young, Nawal M. Nour, Robert C. Macauley, Sandeep K. Narang, Crista
Johnson-Agbakwu, SECTION ON GLOBAL HEALTH, COMMITTEE ON
MEDICAL LIABILITY AND RISK MANAGEMENT and COMMITTEE ON
BIOETHICS
Pediatrics 2020;146;
DOI: 10.1542/peds.2020-1012 originally published online July 27, 2020;
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/146/2/e20201012
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. Pediatrics is owned, published, and trademarked by
the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2020
by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Diagnosis, Management, and Treatment

Female genital mutilation or cutting (FGM/C) involves medically unnecessary abstract

To cite: Young J, Nour NM, Macauley RC, et al. AAP SECTION

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CLINICAL HISTORY TAKING

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If FGM/C is suspected to have

If FGM/C is identiﬁed on examination,

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FROM THE AMERICAN ACADEMY OF PEDIATRICS

PEDIATRICS Volume 146, number 2, August 2020

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statute of some states.

such as reasoning ability and

related to reproductive health

a minor patient who is legally

The second exception involves

Again, state laws vary as to the

outside the scope of the statute.

state, such as getting married or

providers not assume a minor is

of its complications could impact

be deemed sufﬁciently mature to

such as being self-supporting and

or having obtained one’s diploma.

emancipated. Emancipation98 may

The third exception involves being

being assessed for relevant factors

minor fulﬁlls speciﬁc requirements

It is recommended that health care

either being enrolled in high school

precise requirements for a minor to

treatment but not to others that fall

be automatically conferred by taking

make her own health care decisions.

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