Nawal M. Nour

Health Consequences of Child Marriage in Africa

Comprehensive, multifaceted policies are needed to end child marriage and protect girls and their offspring.

Female genital cutting: clinical and cultural guidelines.

Clinical guidelines for managing women who have undergone female genital cutting are essential in providing appropriate and culturally competent care. The objectives of this study were to review the literature, describe the types of female genital cutting, evaluate its immediate and long-term complications, and provide clinical guidelines for managing women who have undergone this procedure. We conducted an extensive literature search on the MEDLINE database (1966–2003) for articles pertaining to female circumcision/genital mutilation/cutting. The search was extended further by citations in these journals not identified in MEDLINE. National and international nongovernmental organizations provided articles not available in American libraries. The author has developed guidelines based on personal experience and recommendations from the literature. The major inclusion criteria limited the search to: 1) English language, 2) medical journals, 3) WHO publications, 4) medical society publications, 5) case studies and statistical data on medical complications, 6) infertility and sexual issues, 7) U.S. legal practice, and 8) deinfibulation. The exclusion criteria pertained to articles: 1) reviewing the literature, 2) lacking epidemiologic data, 3) addressing political and ethical issues, and 4) discussing international concerns. Immediate complications include hemorrhage, infection, urinary dysfunction, shock, or death. Long-term complications include urinary complications, scarring, pain, infection, and infertility. Obstetric complications include lacerations, wound infections, postpartum hemorrhage, and sepsis. Fetal complications are rarely seen in Western countries. Women who have undergone female genital cutting can experience complications. Practitioners must recognize the type of circumcision, ensure cultural competency, and provide appropriate clinical care. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to describe the various types of female genital cutting, to outline the parts of the world that practice such procedures, and to list the immediate and long-term complications of female genital cutting.

Defibulation to treat female genital cutting : Effect on symptoms and sexual function

OBJECTIVE: Women who have undergone type III female genital cutting may suffer long-term complications. Defibulation (reconstructive surgery of the infibulated scar) can alleviate some of these complications. We studied the physical and sexual outcomes after defibulation and evaluated both patient and husband satisfaction. METHODS: The medical records of 40 consecutive women with a history of type III female genital cutting who underwent defibulation between 1995 and 2003 were reviewed. Data collected included demographics, indications for the procedure, closure type, intraoperative and postoperative complications. Telephone surveys were conducted between 6 months and 2 years postprocedure to evaluate the long-term health and sexual satisfaction outcomes. RESULTS: Of 40 women identified as having undergone defibulation, 95% were Somali, 65% were married, and 73% were between the ages of 19 and 30. Primary indications for defibulation were being pregnant (30%), dysmenorrhea (30%), apareunia (20%), and dyspareunia (15%). Secondary indications were apareunia (20%), difficulty urinating (12.5%), and dyspareunia (10%). Sixty-five percent had a subcuticular repair. Forty-eight percent had an intact clitoris buried beneath the scar. None had intraoperative or postoperative complications. Of the 32 patients reached by telephone, 94% stated they would highly recommend it to others. One hundred percent of patients and their husbands were satisfied with the results, felt their appearance had improved, and were sexually satisfied. CONCLUSION: Defibulation is recommended for all infibulated women who suffer long-term complications. The complication rates are minimal, with high satisfaction rates among patients and their husbands. LEVEL OF EVIDENCE: II-3

Female Genital Cutting and HIV Transmission: Is There an Association?

Female Genital Cutting (FGC) refers to the practice of surgically removing all or part of the female external genitalia for non‐medical purposes. It is a common practice in many countries in Africa, the Middle East, and to a lesser extent, Asia. Over 130 million women worldwide have undergone this procedure, and over 2 million women and girls are subject to it every year. Various complications have been described, including infection, hemorrhage, genitourinary and obstetric complications, as well as psychological sequelae. Since the beginning of the HIV epidemic, a few reports have also described a potentially elevated risk of HIV transmission among women with FGC. In this report, we aim to review the evidence and identify unanswered questions and research gaps regarding a potential association between FGC and HIV transmission.

Female genital cutting: impact on women's health.

More than 130 million women worldwide have undergone female genital cutting (FGC). FGC is practiced in parts of Africa and Asia, in societies with various cultures and religions. Reasons for the continuing practice of FGC include rite of passage, preserving chastity, ensuring marriageability, religion, hygiene, improving fertility, and enhancing sexual pleasure for men. The World Health Organization has classified FGC into four types depending on the extent of tissue removed. Immediate complications include hemorrhage, infection, sepsis, and death. Long-term complications include pain, scarring, urinary issues, and poor obstetric and neonatal outcomes. Efforts are being made nationally and internationally to eradicate this practice. In December 2012, the UN General Assembly accepted a resolution on the elimination of FGC. Although it is illegal to perform FGC in the United States, women from countries where the practice occurs have been and are still immigrating here. Many enter as refugees from war-torn, famine-stricken, or politically unstable countries. They bring along with them their cultural pride, health complications, and fears of being judged when visiting a health provider. A deeper understanding of the history, cultural beliefs, medical complications, and methods of surgical reconstruction is necessary to provide culturally and linguistically competent care to this unique group of women.

Cross-Cultural Obstetric and Gynecologic Care of Muslim Patients.

With the growing number of Muslim patients in the United States, there is a greater need for obstetrician-gynecologists (ob-gyns) to understand the health care needs and values of this population to optimize patient rapport, provide high-quality reproductive care, and minimize health care disparities. The few studies that have explored Muslim womens health needs in the United States show that among the barriers Muslim women face in accessing health care services is the failure of health care providers to understand and accommodate their beliefs and customs. This article outlines health care practices and cultural competency tools relevant to modern obstetric and gynecologic care of Muslim patients, incorporating emerging data. There is an exploration of the diversity of opinion, practice, and cultural traditions among Muslims, which can be challenging for the ob-gyn who seeks to provide culturally competent care while attempting to avoid relying on cultural or religious stereotypes. This commentary also focuses on issues that might arise in the obstetric and gynecologic care of Muslim women, including the patient-physician relationship, modesty and interactions with male health care providers, sexual health, contraception, abortion, infertility, and intrapartum and postpartum care. Understanding the health care needs and values of Muslims in the United States may give physicians the tools necessary to better deliver high-quality care to this minority population.

Female genital cutting: a need for reform

Female genital cutting (also known as female circumcision or genital mutilation) is a tradition that transcends religion, socioeconomic status, and geography. Although its origins are a mystery, the practice survives today, reinforced by customs and beliefs regarding ensuring marriageability, rites of passage, maintaining girls’ chastity, hygiene, preserving fertility, and enhancing sexual pleasure for men (American College of Obstetricians and Gynecologists. Female circumcision/female genital mutilation: Clinical management of circumcised women [slide–lecture kit]. Washington: American College of Obstetricians and Gynecologists, 1999). Local midwives routinely perform the procedure on girls between the ages of 6 and 12. Minimal or no anesthesia is used, and antiseptics are rare. Girls who have undergone female genital cutting suffer lifetime risks of complications. These health risks depend on the severity of the procedure, the practitioner’s skill, the instruments used, and the postoperative care. Immediate complications include cellulitis, sepsis, urinary retention, hemorrhage, shock, and even death. Long-term complications seen predominantly in women who have undergone type III (removal of all external genitalia and suturing of remnant tissue) include cysts, abscesses, recurrent infections, dyspareunia, and dysmenorrhea due to the infibulated scar overlying the introitus. Clitoral neuromas, as described by FernándezAguilar and Noël in this issue, are rare. The most common complaint related to neuromas is sharp, excruciating pain. Patients suffer from acute localized dyspareunia. Curative measures include excision of the neuroma, and may require deinfibulation. Deinfibulation, the surgical reconstruction of the infibulated scar, is performed by making an anterior incision on the scar and creating two neo–labia majora. Deinfibulation enables clitoral neuromas to be better visualized and dissected away. It also decreases the incidence of other long-term complications. Female genital cutting is a health and human rights issue. Driven by cultural forces, the incidence of this practice remains high in certain countries. Finding various methods of eradication is not only necessary but also absolutely essential for the well-being of women. Documenting all health complications in the medical literature, like the case report in this issue, is one method that can demonstrate to health providers and policy makers that women have a lifetime of suffering. Organizations like The American College of Obstetricians and Gynecologists (http://www.acog.org) and the African Women’s Health Center (http://www. brighamandwomens.org/africanwomenscenter) are educating health providers, African women, and policy makers here about the sensitive issues of female genital cutting. Although international efforts are critical, it is vital that national governments commit to abolishing female genital cutting. A united front through direct communication, education, and collaboration of international organizations, medical associations, ministries of health, funders, and grassroots organization is paramount to continue the efforts of eradicating this practice.

Global women's health – A global perspective

Abstract The burden of disease and public health issues affecting girls and women throughout their lives is significantly greater in resource-poor settings. These women and girls suffer from high rates of maternal mortality, obstetric fistulas, female genital cutting, HIV/AIDS, malaria in pregnancy, and cervical cancer. Although the Millennium Development Goals (MDGs) are being met in some nations, the majority of the goals will not be reached by 2015. In addition, insufficient attention is given to non-communicable and chronic diseases such as diabetes, hypertension, hypercholesterolemia, cardiovascular diseases, stroke, obesity, and chronic respiratory diseases. A life-course approach that includes improvements in earlier-life factors such as diet and exercise is necessary to improve womens long-term health outcomes. Innovative diagnostic tools and treatment strategies along with cost-effective health service delivery systems are needed to make a significant impact on womens and girls’ health worldwide.

Striving for Respectful Maternity Care Everywhere

Purpose The mistreatment of women during childbirth in health facilities is a growing area of research and public attention. Description In many countries, disrespect and abuse from maternal health providers discourage women from seeking childbirth with a skilled birth attendant, which can lead to poor maternal and neonatal outcomes. This commentary highlights examples from three countries—Kenya, Mexico and the United States—and presents different forms of mistreatment during childbirth, which range from physical abuse to non-consented care to discriminatory practices. Assessment Building on the momentum from the United Nations Sustainable Development Goals, the International Federation of Gynecology and Obstetrics, and the Global and Maternal Neonatal Health Conference, the global community has placed respectful maternity care at the forefront of the maternal and neonatal health agenda. Conclusion Research efforts must focus on context-specific patient satisfaction during childbirth to identify areas for quality improvement.

Benign vaginal villi noted at time of defibulation of female genital cutting.

BACKGROUND: Female genital cutting is a cultural practice in Africa and the Middle East. As more patients who have undergone this procedure are seen in the United States and undergo surgical revision of the scarred labia, new clinical findings will arise. CASE: At the time of surgical revision of female genital cutting, small clusters of villi were noted on the vaginal and labial mucosa of 3 patients. Pathological examination revealed benign-appearing papillary structures. These villi completely resolved by the 6-week postoperative visit. CONCLUSION: Female genital cutting may lead to a vaginal environment that predisposes women to benign changes in the vaginal mucosa that resolve after the closed (infibulated) labia are surgically revised.