Peer-reviewed article

Plastic Surgeon Familiarity with Female Genital Mutilation and Cutting in the United States

Ava G. Chappell, Mona Ascha, Rachita Sood, Kathryn E. Fay, Melissa Andrea Simon et al. · 21 Mar 2022

Abstract

Over 513,000 girls and women in the United States are at risk or are victims of female genital mutilation/cutting.1 Female genital mutilation/cutting is defined as partial or complete excision of external genitalia or injury to the genital organs for nonmedical reasons.2 A scoping review of surgical interventions for female genital mutilation/cutting–related morbidity confirmed that the majority of female genital mutilation/cutting care is delivered by obstetrics and gynecology providers.3 However, procedures such as clitoral reconstruction, scar excision, neuroma treatment, and functional and aesthetic reconstruction fall within the scope and expertise of plastic surgeons.4 To assess familiarity with female genital mutilation/cutting, a 33-question survey was deployed to 3628 members of the American Society of Plastic Surgeons. Three-hundred sixty-three members responded (10 percent response rate). Most respondents were cis male (n = 224, 61.7 percent), White (n = 280, 77.1 percent), and born in the United States (n = 300, 82.6 percent). Respondents consisted of 217 attending physicians (59.8 percent) and 123 trainees (33.8 percent). Respondents were similar to nonresponders and the general American Society of Plastic Surgeons membership. A similar survey was deployed to 5000 obstetrics and gynecology physicians through the American College of Obstetricians and Gynecologists, with a 9.8 percent response rate (n = 491). Eighty percent of plastic surgery respondents (n = 285) reported no prior education or training on female genital mutilation/cutting, 84.5 percent were unfamiliar with the World Health Organization classification system of female genital mutilation/cutting, and 88.4 percent were uncertain of existing clinical management guidelines at hospital, national, or international levels (Table 1). Female genital mutilation/cutting has been formally banned in the United States since 1996; yet, 19 states do not currently have legislation in place criminalizing female genital mutilation/cutting.5 The most commonly selected location of where female genital mutilation/cutting is practiced was Africa (n = 324, 89.3 percent); it can be practiced in any country where communities from endemic areas are living.6 Respondents believed cultural tradition (n = 284, 78.2 percent), control of women’s sexuality (n = 258, 71.1 percent), and religion (n = 250, 68.9 percent) were reasons why it is performed. All listed immediate and chronic physical risks were selected at similar frequency. Most respondents (n = 196, 54.0 percent) indicated that female genital mutilation/cutting can occur repeatedly through a woman’s childhood and adult life; while it is usually performed before age 15, it can be performed at any age.7 Table 1. - Knowledge and Training Related to Female Genital Mutilation/Cutting According to Plastic Surgery Respondents Survey Item Response All Respondents Total no. of respondents 363 Have you received any kind of education or training on FGM/C? Yes 62 (17.3) No 285 (79.6) Uncertain 11 (3.1) Are you familiar with the WHO classification system for FGM/C (types I, II, III, IV)? Yes 29 (8.5) No 289 (84.8) Uncertain 23 (6.7) Where is FGM/C practiced? Africa 324 (89.3) Europe 125 (34.4) Asia 188 (51.8) Australia/Oceania 88 (24.2) North America 112 (30.9) South America 103 (28.4) Why is FGM/C performed? Religious reasons 250 (68.9) To control women’s sexuality 258 (71.1) To ensure virginity before marriage and fidelity in marriage 168 (46.3) Hygiene 39 (10.7) Cultural tradition 284 (78.2) Punishment 111 (30.6) Uncertain 46 (12.7) Immediate physical risks associated with FGM/C include: Hemorrhage 300 (82.6) Hemorrhagic, neurogenic, or septic shock 280 (77.1) Genital and reproductive tract infections 313 (86.2) Urinary tract infections 290 (79.9) Acute urinary retention 251 (69.1) Dysuria 269 (74.1) Damage to urethra 306 (84.3) Death 251 (69.1) Other 11 (3.0) Long-term risks associated with FGM/C include: Chronic wounds 292 (80.4) Chronic vulvar and clitoral pain 317 (87.3) Sexual dysfunction 323 (89.0) Urethral fistulas and strictures 307 (84.6) Recurrent UTIs 287 (79.1) Complicated deliveries: cesarean delivery, postpartum hemorrhage, episiotomy, labor dystocia, obstetrical tears/lacerations, extended maternal hospital stay, infant resuscitation at delivery 284 (78.2) Mental illness: depression, PTSD, anxiety 312 (86.0) Other 3 (0.8) FGM/C can occur: Once in childhood 112 (30.9) Several times in childhood 73 (20.1) Repeatedly throughout a woman’s childhood and adult life 196 (54.0) Uncertain 96 (26.4) Are you aware of any existing guidelines regarding clinical management and/or legal requirements for FGM/C at the following levels? In the hospital(s) where I practice 2 (0.6) At the national level 9 (2.5) At the international level 16 (4.4) Uncertain 321 (88.4) Are you interested in knowing more about FGM/C? Yes 192 (59.3) No 68 (21.0) Uncertain 64 (19.8) What form of education or training would you find helpful on this topic? Assigned reading 8 (2.5) Guest speaker who has FGM/C or is expert in FGM/C 72 (22.8) I would not find any form of education or training helpful on this topic 34 (10.8) Lecture 37 (11.7) Lecture series 26 (8.2) Online modules 102 (32.3) Other (please describe) 6 (1.9) Self-directed learning 31 (9.8) FGM/C, female genital mutilation/cutting; WHO, World Health Organization; UTIs, urinary tract infections; PTSD, posttraumatic stress disorder. Two-hundred ninety-one respondents (87.7 percent) had never treated a patient with female genital mutilation/cutting. A large majority (81.5 percent) believed that plastic surgeons have a role in female genital mutilation/cutting care, and 56.2 percent believed they have a role in advocacy for laws to prevent the practice. Nearly 60 percent were interested in learning more. Obstetrics and gynecology physicians were significantly more likely than plastic surgeons to have received female genital mutilation/cutting education [n = 204 (41.6 percent) versus n = 62 (17.3 percent), p < 0.001], be familiar with female genital mutilation/cutting classification [n = 181 (36.9 percent) versus n = 29 (8.5 percent), p < 0.001], and have had encounters with female genital mutilation/cutting patients [n = 114 (23.4 percent) versus n = 256 (79.0 percent), p < 0.001 for no encounter]. Our results highlight an important knowledge gap of the epidemiology and practice of female genital mutilation/cutting, screening and diagnosis, and pertinent regulations. Online learning platforms, such as the American Society of Plastic Surgeons Education Network and virtual grand rounds, were the preferred methods for learning about this topic. Plastic surgeons possess the technical expertise to treat the diverse, chronic sequelae of female genital mutilation/cutting. There are opportunities for multidisciplinary collaboration and referral clinics, particularly with obstetrics and gynecology colleagues. With increased awareness and education, we can improve the quality of life for women and girls living with female genital mutilation/cutting. ACKNOWLEDGMENTS The authors would like to acknowledge Christopher Simmons, an analyst from the American Society of Plastic Surgeons, for his assistance with deploying the survey. DISCLOSURE The authors have no significant conflicts of interest or financial interests in relation to the content of this article. The Buehler Center for Health Policy and Economics in Northwestern’s Feinberg School of Medicine funded this study in part. Dr. Chappell performed this research during a funded research year sponsored by the Institute for Global Health at Northwestern University.