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Female Genital Mutilation / Cutting (FGM/C)

Female genital mutilation / cutting (FGM/C) comprises all procedures involving partial or total removal of the external female genitalia, or other injury to the female genital organs, for non-medical reasons. WHO and UNICEF estimate > 230 million women and girls alive today have undergone FGM/C across > 30 countries.[1][2] For the reconstructive surgeon and urogynecologist, FGM/C is a structural condition: it determines vulvar/clitoral anatomy, urethral and introital access, sexual function, obstetric risk, and the operative planning for defibulation, clitoral reconstruction, and flap-based vulvar restoration.

WHO Classification​

TypeDescriptionNotes
I — ClitoridectomyIa prepuce only; Ib prepuce + partial/total glans clitoridisClitoral body and crura typically preserved beneath scar — anatomic basis for the Foldès reconstruction
II — ExcisionIIa: labia minora only; IIb: glans clitoris + labia minora; IIc: glans clitoris + labia minora + labia majoraMost common type globally
III — InfibulationNarrowing of the vaginal orifice by apposition of labia minora and/or majora, ± clitoral excision~10% of cases; concentrated in Somalia, Djibouti, Eritrea, northern Sudan
IVAll other harmful non-medical procedures: pricking, piercing, incising, scraping, cauterizationHeterogeneous

Internal clitoral tissue may remain beneath the scar after Type I/II; its individual anatomy and innervation must be assessed when discussing reconstruction.[1][3]

Epidemiology​

  • Pooled global prevalence among women 15–49 in studied countries: ~36.9%; Somalia 99.2% highest in women, Mali 72.7% highest in girls.[4]
  • Pooled sub-Saharan African prevalence across ten high-risk countries: 53.5%.[5]
  • Most procedures occur between ages 4–14; in half of countries with available data the majority occur before age 5.[1]
  • In the United States, the CDC estimates > 500,000 women and girls have undergone or are at risk for FGM/C — primarily through migration from high-prevalence countries.[1]
  • Risk factors: family history (AOR 13.71), lower maternal education (AOR 3.28), rural residence (AOR 2.27), poverty (AOR 1.38).[5][6]
  • Prevalence is declining in most practicing countries but not at a rate compatible with the UN SDG elimination target by 2030.[4]

Health Complications (Reconstructive Focus)​

Risk varies with the actual injury and infibulation; classification alone does not predict an individual’s sexual function or all complications.[1][2]

Immediate​

  • Hemorrhage (clitoral dorsal artery or labial branches; reported in 4–19%), hypovolemic shock
  • Sepsis — cellulitis, abscess, gangrene, tetanus
  • Urinary — urethral injury, retention, edema
  • Fractures from physical restraint

Long-term — reconstructive-urology / urogyn relevance​

DomainLesion / sequelOperative implication
UrinaryUrethral stricture, meatal obstruction, recurrent UTI / pyelonephritis, post-void dribblingMay require meatoplasty, urethral dilation, or defibulation to expose the meatus
VulvovaginalIntroital stenosis, apareunia, retained menses (hematocolpos), epidermoid inclusion cysts, post-FGM neuromasDefibulation; cyst excision; neuroma resection or fat grafting
SexualDyspareunia (OR 2.47), reduced satisfaction, reduced lubricationDefibulation; clitoral reconstruction; FGM/C fat grafting
ObstetricProlonged / obstructed labor (OR 2.04), perineal tears (OR 2.63), episiotomy (OR 1.89), PPH, fetal distress, stillbirthDiscuss antepartum or intrapartum deinfibulation according to circumstances and preference
Mental healthPTSD symptoms, depression, anxiety and somatization; reported prevalence depends on population and assessmentMultidisciplinary care before reconstructive surgery

Predictors of PTSD severity include older age at the procedure, sexual dysfunction, and trauma history; psychological resilience is protective.[7][8]

Clinical Management​

The AAP 2020 clinical report addresses girls; WHO 2025 provides the updated broader clinical framework.[1] Key positions:

  • Providers must never perform any form of FGM/C (including "ritual nick").
  • Counsel families against the practice — including before travel ("vacation cutting").
  • Examine external genitalia at every health-supervision visit and document FGM/C type using ICD-10 N90.810–N90.818.
  • Offer counseling about deinfibulation for Type III; WHO’s recommendation is conditional and requires informed consent.
  • Evaluate for child abuse if FGM/C is suspected to have occurred within the US or by trafficking abroad.

Defibulation (deinfibulation)​

Surgical opening of the infibulated scar to expose the urethral meatus and vaginal introitus.[1][9]

  • WHO 2025 conditionally recommends deinfibulation for Type III, with counseling and informed consent; reinfibulation should not be performed.[18]
  • Antepartum or intrapartum timing can be considered; no universal second-trimester rule is supported. Discuss access, obstetric circumstances, skills and the woman’s preference.[18]
  • Individualize anesthesia and trauma-informed support; local anesthesia is an option, not a categorical contraindication.[19]
  • Very-low-certainty meta-analysis data: defibulation reduces emergency cesarean (OR 0.16) and genital-tract lacerations (OR 0.48) vs non-deinfibulated Type III women.[9]
  • Patient acceptance is high; one series reported 94% would recommend the procedure and 100% were pleased with results.[1]

Clitoral and vulvar reconstruction​

The reconstructive armamentarium has matured into four major techniques, each detailed in the treatment atlas:

  • Foldès clitoral reconstruction — scar excision, suspensory-ligament division, mobilization of the retained clitoral body. In the largest prospective cohort, 2,938 underwent surgery but only 866 (29%) attended one-year follow-up; 430/841 assessed reported orgasm. Immediate complications occurred in 155/2,938 (5%). Attrition, selected outcomes and the absence of an untreated comparator limit causal interpretation; this is not a 51% restoration rate for all operated women.[21]
  • O'Dey anatomical reconstruction with aOAP flap — anterior obturator artery perforator flap recreates labia minora and clitoral hood; significant postoperative reduction in dysmenorrhea, dysuria, dyspareunia (n = 119; FGM/C 36% of indications).[12]
  • Mañero vaginal mucosal graft — a graft-based reconstructive variant; comparative effectiveness is uncertain.[11]
  • FGM/C fat grafting — a selected scar/pain intervention with limited evidence; not an established treatment for all FGM/C-related sexual symptoms.[11]

WHO 2025 conditionally suggests clitoral reconstruction for selected women, alongside sexual-health counseling; evidence is very low certainty and benefits are not assured.[18] Evidence certainty across reconstructive techniques is very low in formal SR grading; preoperative sexual-health counseling and multidisciplinary assessment are important.[10][13] See also the vulvar reconstruction landing / database for cross-indication algorithm placement.

  • US federal: Federal Prohibition of FGM Act 1996 criminalized FGM/C on minors. A 2018 district-court ruling (US v Nagarwala) found the federal statute unconstitutional on commerce-clause grounds. The STOP FGM Act of 2020 revised the federal prohibition in 18 USC §116.[20] State laws and reporting duties vary and require current jurisdiction-specific checking.[1][14]
  • Vacation cutting: Transport for Female Genital Mutilation Act 2013 criminalized taking a child abroad for FGM/C.
  • International: UN frames FGM/C as torture and a human-rights violation; the 2025 WHO guideline emphasizes integrated health-system, legal, community-education, and survivor-centered approaches.[15]

Culturally Sensitive Communication​

Discussions require cultural humility without compromising the medical-risk and legal messaging. The AAP recommends standardized provider training in identification, treatment, and culturally appropriate communication.[1][16] Defibulation decisions are often staged across multiple visits to address fear, family pressure, and mental-health needs; survivor- and partner-perspectives qualitative work supports flexible timing options.[1][17]

See Also​

References​

1. Young J, Nour NM, Macauley RC, Narang SK, Johnson-Agbakwu C. Diagnosis, management, and treatment of female genital mutilation or cutting in girls. Pediatrics. 2020;146(2):e20201012. doi:10.1542/peds.2020-1012

2. Pallitto C, Ruiz-Vallejo F, Mochache V, et al. Exploring the health complications of female genital mutilation through a systematic review and meta-analysis. BMC Public Health. 2025;25(1):1387. doi:10.1186/s12889-025-21584-z

3. Botter C, Sawan D, SidAhmed-Mezi M, et al. Clitoral reconstructive surgery after female genital mutilation/cutting: anatomy, technical innovations and updates of the initial technique. J Sex Med. 2021;18(5):996–1008. doi:10.1016/j.jsxm.2021.02.010

4. Farouki L, El-Dirani Z, Abdulrahim S, et al. The global prevalence of female genital mutilation/cutting: a systematic review and meta-analysis of national, regional, facility, and school-based studies. PLoS Med. 2022;19(9):e1004061. doi:10.1371/journal.pmed.1004061

5. Luoga P, Paulo HA, Mbishi JV, et al. Prevalence and determinants of female genital mutilation: current insights from ten at-risk countries in sub-Saharan Africa. BMC Public Health. 2025;25(1):1031. doi:10.1186/s12889-025-22279-1

6. Ayenew AA, Mol BW, Bradford B, Abeje G. Prevalence of female genital mutilation and associated factors among women and girls in Africa: a systematic review and meta-analysis. Syst Rev. 2024;13(1):26. doi:10.1186/s13643-023-02428-6

7. Wulfes N, von Fritschen U, Strunz C, et al. Cognitive-emotional aspects of post-traumatic stress disorder in the context of female genital mutilation. Int J Environ Res Public Health. 2022;19(9):4993. doi:10.3390/ijerph19094993

8. Keles E, Bilge Y, Öztürk M, et al. Mental health outcomes and post-traumatic stress disorder associated with female genital mutilation. Sci Rep. 2025;15(1):19489. doi:10.1038/s41598-025-03878-9

9. Okusanya B, Esu E, Nwachuku N, et al. Deinfibulation for improving obstetric, neonatal, gynecologic, and sexual-health outcomes in women and girls with Type III female genital mutilation: a systematic review and meta-analysis. Int J Gynaecol Obstet. 2026;172(Suppl 1):31–47. doi:10.1002/ijgo.70759

10. Meremikwu C, Oringanje C, Moses C, et al. Clitoral reconstructive surgery in women and girls living with female genital mutilation: a systematic review. Int J Gynaecol Obstet. 2026;172(Suppl 1):81–94. doi:10.1002/ijgo.70760

11. Almadori A, Palmieri S, Coho C, et al. Reconstructive surgery for women with female genital mutilation: a scoping review. BJOG. 2024;131(12):1604–1619. doi:10.1111/1471-0528.17886

12. O'Dey DM, Kameh Khosh M, Boersch N. Anatomical reconstruction following female genital mutilation/cutting. Plast Reconstr Surg. 2024;154(2):426–438. doi:10.1097/PRS.0000000000011026

13. Lurie JM, Weidman A, Huynh S, et al. Painful gynecologic and obstetric complications of female genital mutilation/cutting: a systematic review and meta-analysis. PLoS Med. 2020;17(3):e1003088. doi:10.1371/journal.pmed.1003088

14. Bootwala Y. Exploring opposition to ritual female genital cutting since the first U.S. federal prosecution: the 2017 Detroit case. Int J Impot Res. 2023;35(3):179–186. doi:10.1038/s41443-022-00532-0

15. Ehiri JE. Health systems approaches and other multisectoral efforts for primary prevention of female genital mutilation and clinical management of its complications. Int J Gynaecol Obstet. 2026;172(Suppl 1):3–8. doi:10.1002/ijgo.70767

16. Hearst AA, Molnar AM. Female genital cutting: an evidence-based approach to clinical management for the primary care physician. Mayo Clin Proc. 2013;88(6):618–629. doi:10.1016/j.mayocp.2013.04.004

17. Jones L, Danks E, Costello B, et al. Views of female genital mutilation survivors, men and health-care professionals on timing of deinfibulation surgery and NHS service provision: qualitative FGM Sister study. Health Technol Assess. 2023;27(3):1–113. doi:10.3310/JHWE4771

18. World Health Organization. WHO guideline on the prevention of female genital mutilation and clinical management of complications. 2025. Recommendations.

19. Royal College of Obstetricians and Gynaecologists. Female Genital Mutilation and its Management. Green-top Guideline No. 53. 2015. Guideline.

20. United States Code. 18 USC §116: Female genital mutilation. Current statute.

21. Foldès P, Cuzin B, Andro A. Reconstructive surgery after female genital mutilation: a prospective cohort study. Lancet. 2012;380(9837):134–141. doi:10.1016/S0140-6736(12)60400-0.