Female Genital Mutilation/Cutting (FGM/C) Clinical Management Guide

Overview

Female genital mutilation/cutting (FGM/C) is the partial or complete removal of the external female genitalia for non-medical reasons. It is practiced in parts of Africa and the Middle East, and is a criminal offence in Canada including sending a child abroad to undergo the procedure.

FGM/C has no medical benefits and is associated with significant physical and psychological harm.

WHO Classification

- Type I — Partial or total removal of the clitoris and/or prepuce (clitoridectomy)
- Type II — Partial or total removal of the clitoris and labia minora, with or without excision of the labia majora (excision)
- Type III — Narrowing of the vaginal orifice by cutting and repositioning the labia (infibulation) — most severe form
- Type IV — All other harmful procedures (pricking, piercing, incising, scraping, cauterization)

Chronic Complications

Patients may present with any of the following:

- Anorgasmia, dyspareunia, vaginal dryness
- Chronic vulvar, vaginal, or lower abdominal pain
- Dysmenorrhea, vaginal stenosis
- Recurrent urinary tract infections
- Obstetrical complications (especially Type III)
- Long-term psychological impacts including PTSD and anxiety

Screening

Routine screening is not recommended for all patients. Screen when:

- Patient is pregnant or planning a pregnancy
- A gynecological procedure (e.g. Pap test) is planned
- Patient is from a high-prevalence country AND has any of the complications listed above

**How to screen:** Use the word "circumcision" rather than "mutilation" when asking patients. Ask about the history (where, when, how), current symptoms, and beliefs. Offer an external genital examination to classify type and guide management.

**For parents of young girls** from high-prevalence countries: raise the topic once trust is established. Educate about Canadian law — FGM/C and sending a child abroad for the procedure are both criminal offences.

Management

- Refer to Gynecology for any patient with associated symptoms or who is interested in defibulation
- Pregnant patients or those planning pregnancy should be referred promptly — defibulation can be performed ante- or intrapartum
- Patients under 16 should be referred to Pediatric Gynecology

Calgary Context

- Gynecology referral: through family physician or directly to the Foothills Medical Centre Women's Health
- For patients under 16: Alberta Children's Hospital Pediatric Gynecology