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Feb 28, 2015 - residents who have undergone FGM (5), and in Sudan and in ... 2 Sciences for Health Promotion and Mother and Child “G. D'Alessandro”, University of .... on the wound (local), or also systemic, abscesses, ulcers, up .... necrosis and formation of a vesicovaginal fistula (27). .... care professionals (HCPs).
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Urologia 2015; 82 (3): 151-159 DOI: 10.5301/uro.5000115

REVIEW

ISSN 0391-5603

Female genital mutilations: genito-urinary complications and ethical-legal aspects Marco Vella1, Antonina Argo2, Angela Costanzo1, Lucia Tarantino1, Livio Milone2, Carlo Pavone1 1 2

Surgical Disciplines, Oncology and Dentistry, University of Palermo, Palermo - Italy Sciences for Health Promotion and Mother and Child “G. D'Alessandro”, University of Palermo, Palermo - Italy

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ABSTRACT Many women in the world are still undergoing female genital mutilations (FGMs) even if in almost all the countries, the practice of FGM is illegal. The increase of immigration, particularly from African Countries, to Europe, and Italy too, led to consider this phenomenon with particular attention and skill. All the operators in health services need to know the different types of FGMs and the related complications and the psychological and sexual sequels. Urological complications, in particular, are not rare and the changing anatomy of the external genital apparatus can also make the catheter insertion sometimes difficult. This review analyzes the epidemiology of FGMs, the reasons why the practice is still made, the complications, the ethical, and the principal legal aspects of this practise that must be hopefully early banned. Keywords: Female genital mutilation, Epidemiology, Genito-urinary, Sexual complications, Ethico-legal

Introduction

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Materials and Methods

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Female genital mutilations (FGM) (also referred to as “female genital cutting” and “female genital mutilation/ cutting” – FGM/C) concern all procedures involving partial or total removal of the external female genitalia or other damage to the female genital organs for nonmedical reasons (1). FGMs are harmful practices that constitute a serious threat to the health of women and girls, including their psychological, sexual, reproductive, and genitourinary health. It is important to specify the correct term to be used to define these practices. When FGM/C first came to be discussed beyond the societies in which it was traditionally exercised, it was generally referred to as “female circumcision.” This term created confusion (2) because it caused an erroneous parallelism with male practice, that is, in many cases, a not dangerous operation made as a preventive measure of penile cancer, infantile urinary tract infections (UTIs), balanoposthitis, phimosis, and HIV infection (3). In contrast, female genital cutting is, not rarely, harmful to the women. To emphasize the gravity of the FGM/C act, the word “mutilation” was adopted in the 1990s (2).

Accepted: January 28, 2015 Published online: February 28, 2015 Corresponding author: Marco Vella University of Palermo Via del Vespro 129 90127 Palermo, Italy [email protected]

© 2015 Wichtig Publishing

A computerized search on PubMed was made including the following key words: FGM, epidemiology, complications, urological complications, genito-urinary complications, sexual complications, ethico-legal. Only English papers have been considered and the search comprised only the articles from 1980 until now. Cumulatively, 150 papers have been reviewed and considered pertinent for the topic. Six works have been consulted to treat specifically urological complications.

Discussion Epidemiology FGMs are carried out today in 26 African countries and it is estimated that at least 100 million women are mutilated, belonging to very different socioeconomic classes and ethnic and cultural groups, including Christians, Muslims, Jews, and followers of indigenous African religions (4). In particular, Nigeria has the highest absolute number of residents who have undergone FGM (5), and in Sudan and in Somalia, these practices are developed with a rate of 98%, especially the ancient form of FGM, called “pharaonic,” because of its Egyptian origin (6). The practice is also found in some countries in the Middle East and Asia, and among immigrant communities in a number of Western countries, such as Australia, Canada, France, Norway, Sweden, Switzerland, and the United States. It is however believed that the majority of girls do not undergo the procedure in the Western countries where they live, but they are sent to their country of origin, usually in Africa, during summer holidays, in order to undergo the practice (7-10). In spite of the general opinion, the mothers are not adverse

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Partial or total removal of the clitoris* and/ or the prepuce (clitoridectomy).

Removal of the clitoral hood or prepuce only Type Ib: Removal of the clitoris* with the prepuce

Type II: Partial or total removal of the clitoris* and the labia minora, with or without excision of the labia majora (excision)

Type IIa: Removal of the labia minora only Type IIb: Partial or total removal of the clitoris* and the labia minora Type IIc: Partial or total removal of the clitoris*, the labia minora and the labia majora

Type III: Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation)

Type IIIa: Removal and apposition of the labia minora Type IIIb: Removal and apposition of the labia majora

Type IV: Unclassified

All other harmful procedures to the female genitalia for nonmedical purposes, for example, pricking, piercing, incising, scraping, and cauterisation.

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Type I:

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*Notice that when total removal of the clitoris is reported, it refers to the total removal of the external part of the body of the clitoris.

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to FGMs. The reasons why women are favorable to submit their daughters to these procedures are that they consider FGM necessary to maintain proper hygiene, to increase fertility, and to ensure a woman’s chastity (11). Classification

Reasons

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There are many kinds of FGM and the last classification (2007) proposed by WHO (12) recognizes four types of these practices (Tab. I). Type I FGM/C (Fig. 1) is the most common, followed by type II (Fig. 2). Type III (Fig. 3) is the most common in Middle East Africa.

The most important reasons that encourage this custom are fundamentally ethical. In many societies, it is practiced as a rite of passage to womanhood, with strong ancestral and sociocultural roots. The perpetuation of the ritual is supported by preservation of ethnic and gender identity, femininity, female purity/virginity, and “family honor”; other reasons are maintenance of cleanliness and health and assurance of women’s marriage ability. The age for the practice is variable. In Gambia, it is between birth (7 days) up to preadolescence, and usually before the first menstruation and marriage (13). The importance of FGM consists in the fact that among these communities, girls who undergo FGM/C, and their family, are met with social approval, notably respectability, and honor; on the contrary, in response to failure to conform to FGM/C, social mechanisms include insulting an uncut girl’s mother, alienating uncut girls, denying them social acceptance, and, above all, rejecting them as marriage partners.

Fig. 1 - Type I or clitoridectomy or “sunna” (excision of the prepuce and/or the clitoris).

These findings show the role of FGM/C as a tool in social control. Refusing FGM/C would not only makes uncut girls and their families “different” but also isolate them from marriage prospects in their community (14, 15). Complications The consequences of FGM are several and involving many aspects of cut girl's life. © 2015 Wichtig Publishing

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Fig. 2 - Type II means the removal of the clitoris with partial or total excision of the labia minora.

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Fig. 3 - Type III or infibulations or pharaonic in which not only the clitoris but also the labia minora and majora were removed. The orificium vaginae is sewn up, leaving only a small opening for urine or menstruation blood.

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Physical complications

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They can arise as early and late complications. The clitoridectomy can cause hemorrhage and pain, which can lead to shock and death in the worst cases, or to anemia, infections on the wound (local), or also systemic, abscesses, ulcers, up to septicemia, tetanus, and gangrene (16). The infection is one of the most serious complications of FGM. The practice is indeed often performed with no anaesthesia or antibiotics and in the absence of aseptic conditions. The consequence is an increase of infections caused by Chlostridium tetani, Staphylococcus aureus, and Pseudomonas pyocyanea. Also, sexually transmitted diseases are increased and it was recently shown that different types of infections, such as HIV, Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, Candida albicans, Trichomonas vaginalis, and Herpes Simplex Virus Type 2 (HSV-2), were higher in mutilated women than in uncut women. The univariate risk of infection ranged from 0.47 to 5.2 (17). The long-term complications are more typical of infibulation (FGM type 3) than of simple clitoridectomy, because in this case, there is an interference with the urination and menstrual blood drainage. Formation of dermoyd cysts in the line of the scars (caused by keratinization of epithelial cells and sebaceous glands) and formation of keloids (Fig. 4) are complications that generate fear and shame among the cut girls, and also recurrent abscesses can afflict women for many years (16). Another serious long-term problem for these women is the correlation between FGM and HIV transmission. In the © 2015 Wichtig Publishing

context of sexual assault in general, and FGM in particular indeed, the mucosal microenvironment will be profoundly altered, and danger signals will attract and modify the phenotype of immune cells that are also target cells for the HIV, likely influencing HIV susceptibility (18). Urological consequences

Voiding difficulties, recurrent UTIs, and vesicovaginal fistula occur mostly in women with infibulation (19) (Tab. II). About voiding difficulties, immediately after the operation, an acute urinary retention is frequent, and often patients try to avoid the pain by not urinating. The reasons are “tight circumcision” (the urine cannot pass the scar), obstruction by skin flaps, or blood clots. Several works support these kind of complications: in a review, published in 2004, it is estimated that the prevalence of acute urinary retention accounts for 12%, without a difference between the different types of FGM. Teufel and Dörfler reported that three out of 16 women stated that they spent until to 15 min for each urination. Agugua and Egwuatu, analyzing the consultations in a gynecological hospital in Nigeria, demonstrated that 28.8% of the patients suffered from urological problems. Straining and retention of urine associated with metal obstruction and urethral stricture occurred in three pediatric patients, and in other two nonpediatric patients, metal obstruction led to poor urinary flow. Urinary retention occurs, as an early complication, in the first 3 days after FGM and has been attributed to postoperative pain, irritation of the raw areas by urine, and obstruction of the external urethral meatus by skin flaps or blood clots. Late urological complications of FGM are, on the other

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A case of formation of calculus in a 32-year-old infibulated Somalian woman with voiding difficulties is also reported, because urine was retained in the vulva, which led to the formation of a calcium oxalate calculus outside the urinary tract (25). The best form of therapy in patients with voiding difficulties is defibulation. After the operation, the sudden increased flow of urine may be unusual for women usually used to a very thin stream, so it is important to prepare the patient for this. About recurrent urinary tract infections, as urine and blood remain trapped in the sealed vulva, this creates an environment that facilitates bacterial growth, leading to recurrent urinary infections. Compared with the complication “voiding difficulties,” reliable evidence is scarce. Patients of an antenatal outpatient clinic in Melbourne were asked to fill in a questionnaire concerning the health consequences of FGC. Fourteen out of 51 women (27.5%) reported “urinary tract infection,” but just one woman (1.9%) reported “recurrent urinary tract infections.” A bacterial culture with antibiogram in FGM women is highly recommended (20, 23, 26). The third most important urological complications is constituted by Vesicovaginal fistula. The main cause is a prolonged labor in which the weight of the baby’s head puts enormous pressure on the pelvic outlet and the pelvic floor, leading to ischaemic necrosis and formation of a vesicovaginal fistula (27).

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Fig. 4 - Urogynecological complications of FGM: gynecological keloyd.

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hand, the obstruction of the urinary stream by the fused labia, following type 3 FGM, and UTIs. During micturition, the urinary flow first press on the fused labia minora and then exits through the clutched opening in the vulva causing urinary splashing around the perineum and upper thighs (20-25).

Type I and II FGM/C have a negative impact on women’s sexual lives when compared with women who have not undergone FGM/C. The principal problems are dyspareunia (painful intercourse), bleeding during or after intercourse, partner’s difficult penetration, higher rates of vulvar or vaginal pain, and clitoral neuroma. In a work of Rigmor C. Berg, a total of 15 studies were carried out, showing that compared with women without FGM/C, women who had undergone to FGM/C were more subjected to dyspareunia, no sexual desire, and less sexual satisfaction (28). In another study, the effect of FGM on sexual pleasure, comparing a group of women affected by different types of

TABLE II - Urological complications related to female genital mutilations Complication

Reason

Treatment

Urinary retention

Pain, obstruction by skin flaps or blood clots, tight circumcision

Partial or total defibulation, pain relief, temporary catheterisation

Straining

Obstruction by skin flaps or blood clots, tight circumcision

Partial or total defibulation

Slow urinary stream

Tight circumcision Urinary tract infection, fester, open wound

Partial or total defibulation Partial or total defibulation, antibiotics, pain relief

Calculus formation outside the Retained urine that causes a calcium oxalate urinary tract causing sharp pain calculus

Partial or total defibulation

Urinary tract infection

Tight circumcision, accumulation of blood and urine under the infibulation scar

Antibiotics, partial or total defibulation

Urinary incontinence

Tight circumcision (dribbling incontinence) Vesicovaginal fistula after prolonged delivery and necrosis, perineal tears

Partial or total defibulation Fistula repair

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Clinical management

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ficulties to develop a sexual identity (16). The seriousness of the psychological consequences has been demonstrated in a study carried out among a group of Senegalese women in Dakar that showed a significantly higher prevalence of posttraumatic stress disorder (PTSD), memory problems, and other psychiatric syndromes (32). A particular aspect that can be analyzed is that of male complications and attitudes with regard to FGM. In a study conducted in a village in the Gezira Scheme along the Blue Nile in Sudan, among married men of the youngest parental generation and grandfathers, it was found that there are many complications also for men, caused by FGM, such as difficulty in penetration, wounds/infections on the penis, and psychological problems. This is also very interesting because the acknowledged male complications may open new possibilities to withdraw the practice of FGM (33).

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The clinical treatment of these women is a very important argument because their genital’s anatomy is altered and the knowledge among gynecologists, urologists, obstetrician, and healthcare assistants is fundamental. A very simple operation, such as catheterization, indeed, can be complex and can need a particular treatment for a cut woman. Recently, Abdulrahim A. Rouzi showed the technique used to realize a catheterization in a pregnant young woman with a type III FGM. The difficulty of this operation is due to the scar tissue that covers the urethral meatus and part of the vaginal introitus. The procedure consists in cleaning the genital area with an antiseptic solution, inserting a lubricated sterile speculum below the scar, pulling the speculum outward, and then lifting it in an upward direction to expose the urethra for cleaning with antiseptic solution and insertion of a Foley catheter under direct visualization (34). In another study (35), the hospital records of all women from Sudan, Somalia, Ethiopia, Egypt, Eritrea, and Chad were collected who were admitted to King Abdulaziz University Hospital, Jeddah, Saudi Arabia, from January 1, 2011 to January 1, 2012. About 162 women with type III FGM had urinary catheterization and 112 (69.1%) women had urinary catheterization by the standard procedure and 50 (30.9%) by the retraction technique because of failure of the standard procedure. No complications occurred during insertion or while the catheter was in place. This demonstrates that the retraction technique provides a safe and effective option for urinary catheterization of women with type III FGM (35). However, if required by the woman, the best solution is treatment of deinfibulation (Fig. 5), especially when she has to attend her first sexual examination or her first intercourse. After deinfibulation, the edges can be secured in two possible ways: a circular stitching around labia majora (Fig. 6), leaving the vulva area open, permits free flow of urine and menstrual blood, or a traditional ‘reinfibulation’ (the edges are sewn back together to cover urethra and vaginal introitus). However, the second option is considered harmful and ethically uncorrected. Surgeons have to exercise extreme caution in removing a dermoid cyst and incising an abscess in a scared and damaged area as a mutilated genital (16).

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FGM/C with a group of uncut women, has been evaluated (29). The results showed that sexual function in women with FGM is adversely altered in different domains of arousal, orgasm, and satisfaction. However, other studies reported a good sexual health in women with FGM and orgasm in almost 86% (30). In infibulated women, some erectile structures fundamental for orgasm have not been excised and cultural influence can change the perception of pleasure, as well as social acceptance so that FGM/C women can also have the possibility of reaching an orgasm. In FGM women with sexual dysfunction, it was shown that defibulation can ameliorate sexual health, and after defibulation, 14 out of 15 infibulated women reported orgasm. Therefore, FGM/C women with sexual dysfunctions can and must be cured; they have the right to have an appropriate sexual therapy (30). FGM/C also has obstetric complications, including negative repercussions for delivery and the health of the newborn. Complication rates increased dramatically in women with type I or II FGM/C (39.0 and 65.9%, respectively) compared with women who had not undergone FGM/C (11.7%). The obstetric complication most often found in all three groups was perineal tearing, but with a prevalence three times higher for women with type I FGM/C (27.8%) and five times higher for women with type II FGM/C (48.8%) than women who had not undergone FGM/C (9.6%). The higher frequency of perineal tear among women with FGM/C is attributed to loss of elasticity of the perineal tissue because of scar tissue and abnormal scarring (fibrosis and keloids). This loss of elasticity of the perineum is also thought to be related to the much greater prevalence of episiotomy observed for women with type I (20.0%) and type II (30.5%) FGM/C, in comparison with women who had not undergone FGM/C (3.2%). Finally, higher rates of fresh stillbirth were observed for women with type I or II FGM/C, linked to a prolonged second stage of labor, because of obstruction and loss of tissue elasticity (13). Another study, published in 2004, compared women with and without FGM in a Swedish hospital regarding prolonged labor. The most frequent type of FGM in the study group was infibulation (type III) and defibulation was done routinely. The study showed no elevated risk of prolonged labor for women, but if an infibulated woman gives birth to a child without being defibulated in advance, the fetal head may have many difficulties in passing the scar, leading to strong contractions that may lead to risk of ischaemic necrosis of the vesicovaginal tissue and fetal death. Another study was published by the WHO in 2006, in which 28,393 participants were examined in 28 obstetric centres in Burkina Faso, Ghana, Kenya, Nigeria, Senegal, and Sudan, and they stated the existence of an increased risk of certain consequences such as cesarean section, postpartum bleeding, episiotomy, extended maternal hospital stay, infant resuscitation, and inpatient perinatal deaths in FGM women, compared with non-FGM group (9, 16, 31). Obviously, these important physical complications have a very strong effect on psychology of involved women. Although in those countries where the practices are carried out, the psychological concerns are covered by a necessity of acceptant of social norms, for women who live in western countries, psychological sequelae are very serious, as they have many dif-

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acceptance and satisfaction. It restores some of women's natural genital anatomy and offers the potential for improved female sexuality (36). Also, other studies demonstrated that reconstructive surgery after FGM is associated with reduced pain and restored pleasure: in one of these, 866 patients with FGM aged 18 years or older who had consulted a urologist at Poissy-St Germain Hospital, between 1998 and 2009 were evaluable for cosmetic results, pain, and orgasmic function. They were treated for resecting skin covering the stump to reveal the clitoris. The results of 1-year follow-up visited patients were very encouraging: most patients reported an improvement, or at least no worsening, in pain and clitoral pleasure and improved sex life (37). Legal and ethical aspects

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It is known that the practice of FGM is not supported by any western countries neither in Africa. Near 1980, the host countries began to adopt anti-FGM laws: the first was in Sweden, where in 1982, a law was passed that considered all the female mutilation illegal and later in UK, Belgium, the Netherlands, and then in almost all Europe Countries. In France, many cases of FGM were brought as special forms of child's abuse. Also, United States considered the practices illegal and also banned the reinfibulation (16). More recently in Italy, penal code (law number 7 of 2006) took into account rules regarding FGM as an illegal practice for health professionals (38). Consequently, consensus of female, for example, cannot authorize physician to practice femal genital mutilation, within art. 583 bis of the criminal code. Worthy of knowing the article 5 of that Law indicating the so-called “free green call” to declare observed cases of FGM by HCPs or anyone. Possibly, sometimes special concerns are related to the balance between respect of patient freedom, commitment to confidentiality, and legal duties for health professionals, and all must be resolved in the view of major patient beneficence. Although laws are not yet enough, they work in several ways with prevention strategies, such as educational intervention approaches by creating enabling environments for change. Indeed, findings are in agreement with UNICEF, suggesting that comprehensive social support mechanisms and awareness-raising campaigns may be advantageous (7). The abandonment process involves expanding a range of successful projects by health organization, addressing the human rights priorities of communities, which involve a routine approach to potential victims, also in the view of potential child abuse and gender violence, and transmission of infectious diseases (39-43). Internationally, an African Coordinating Centre for abandonment of FGM/C is born in Kenya to share research, to promote solidarity and advocacy, and to implement a coordinated and integrated response to abandon FGM/C. An important role in these programs is covered by healthcare professionals (HCPs). They have the potential to become important agents for the prevention of FGM/C, because they are integrated and legitimated in the community. The involvement of HCPs is particularly urgent in rural areas, where the prevalence of FGM/C is higher than in urban areas, and the quality health services are less controlled (44).

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Fig. 5 - Deinfibulation technique.

Fig. 6 - Circular stitching around labia majora, the less harmful technique used to reproduce the vaginal closure, leaving the vulva area open, and permitting free flow of urine and menstrual blood.

An important aspect of FGM’s management is the reconstructive surgery. Fazari presented a case of a 24-year-old Sudanese female, who had undergone ritual FGM type III and who suffered from a large, vulval mass for the last 6 years and with apareunia. The mass was successfully removed and remaining genital tissues were approximated and sutured. Reconstructive surgery for women who suffer sexual consequences from FGM resulted feasible, with a high degree of

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Considering the still high degree of the event, it is very important to analyze the level of knowledge of the phenomenon, and consequently, several studies have been carried out administering questionnaires among doctors, social assistants, psychologists, nurses, health assistants, and educators. In one of these studies [a multicenter study on knowledge and attitude of nurses in northern Nigeria concerning FGM (45)], determing the knowledge and attitude of nurses in northern Nigeria concerning FGM, it is demonstrated that the nurses studied had a high level of awareness of FGM and a good general knowledge of complications associated with FGM, but not an adequate knowledge of particular forms of FGM. Again, the work of Johnson OE “Perception and practice of female genital cutting in a rural community in southern Nigeria,” carried out to determine the awareness and practice of FGC in a rural community in southern Nigeria, shows that majority of participants (98.6%) were aware of the practice of FGC (46). Even in a city as London, as demonstrated by a study of Relph, the majority of respondents were aware of FGM/C, but their ability to identify the condition and its associated morbidity remain suboptimal (47). In a study, a group of selected male and female students from several faculties of the University of Cairo, was interviewed. Cumulatively seventy-two percent of these students supported the abolishment of female mutilation. The percentages of women and medical students who were against this custom were even higher than men and nonmedical students. Although medical students were significantly more knowledgeable than nonmedical students, the fact that less than half of them knew that hemorrhage and infection could follow female cutting, and the opposing opinions of the other 28% of students, suggests that some action is still needed (11). In order to increase the confidence in the ability of healthcare providers to treat immigrant women with infibulation, a study tried to carry out, in U.S. clinics, an education program that included didactic information, case studies, a cultural roundtable, and a hands-on skills laboratory of deinfibulation and repair. Participants completed a measure-of-confidence survey tool before and after the education intervention. The participants reported increased confidence in their ability to provide culturally competent care to immigrant women with infibulation (48). This is a confirmation that educational programs can be advantageous in order to improve the situation. What is the situation in Italy, one of the countries that is most subjected to immigration? In the study “Health care for immigrant women in Italy: are we really ready? A survey on knowledge about female genital mutilation” by Caroppo, it is reported that among 41 operators working in CARA (Shelter

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for Refugees and Asylum Seekers) in central and southern Italy, interviewed through a questionnaire, only 7.3% of respondents stated that they know FGM well, although 4.9% did not know it at all. About 70.7% declared to have never met or assisted a woman with FGM; nevertheless, all respondents worked with an asylum seeker from countries where FGMs were performed (49). Certainly, migration fluxes to Italy over the past decade created a healthcare challenge: women with FGM have specific medical and psychological problems that doctors, nurses, and social assistants without specific training are not usually able to manage (50). This led to the conclusion that it is essential to improve the knowledge not only of the existence of the phenomenon but also of the specific techniques to be used for this kind of patients. However, as in other European countries, in Italian medical schools, FGMs are not included in pre-graduate curriculum and recent studies enphasize that there is a lack of knowledge on the subject among gynecologists, many of whom are not familiar with the classification and management of FGM. For the best of our knowledge, no studies were conducted among urology specialist aimed to appreciate their competence and attitude in this field of interest. In addition, considering the possible consequences for overall psychophysical health, a multidisciplinary approach is recommended in collaboration with pediatricians, who can play a central role in prevention. It is necessary to continue studying, educating, increasing awareness, and teaching medical professionals to guarantee optimum prevention and care for women with FGM.

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Today, there are several campaigns against FGM, as that managed, in Italy, from Department of Equal Opportunity, or campaigns sustained from OMS or Amnesty International (“End FGM”). It has been instituted since 2010, by OMS, an international day for "Zero Tolerance against FGM" that is celebrated on 6th February.

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Conclusion Despite of many efforts, FGM/Cs are no more obsolete practices. During the times, a variety of sociocultural myths, religious misbelievers, and hygienic and aesthetic concerns were behind the FGM/C. Overall, a large proportion of people supported the continuation of FGM/C in spite of adverse effect and sexual dysfunction associated with FGM/C, for many reasons, generally not acceptable under the human dignity parameter. There is a common and general opinion in favor of the need to improve the knowledge about the argument for all health professionals, and to eliminate and overthrow the phenomenon, which constitutes an unacceptable cause of physical and psychological damages for women who are subjected to it.

Disclosures Financial support: No financial support was received for this sub­ mission. Conflict of interest: The authors have no conflict of interest.

References 1. 2.

WHO. Eliminating female genital mutilation – an interagency statement (OHCHR, UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCR, UNICEF, UNIFEM, WHO). WHO; 2008. Fried S, Mahmoud Warsame A, Berggren V, Isman E, Johansson A. Outpatients’ perspectives on problems and needs related to female genital mutilation/cutting: a qualitative study from Somaliland. Obstet Gynecol Int. 2013; 2013:Article ID 165893, 11 pages.

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12. 13.

14. 15.

16. 17. 18.

19. 20. 21. 22.

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10.

1982;28(5):248-252. 24. Okwudili OA, Chukwudi OR. Urinary and genital tract obstruction as a complication of female genital mutilation: case report and literature review. J Surg Tech Case Rep. 2012;4(1):64-66. 25. Nour NM. Urinary calculus associated with female genital cutting. Obstet Gynecol. 2006;107(2 Pt 2)(Supplement): 521-523. 26. Knight R, Hotchin A, Bayley C, Grover S. Female genital mutilation: experience of The Royal Women’s Hospital, Melbourne. Aust N Z J Obstet Gynaecol. 1999;39:50-54. 27. Browning A, Allsworth JE, Wall LL. The relationship between female genital cutting and obstetric fistulae. Obstet Gynecol. 2010;115(3):578-583. 28. Berg RC, Denison E. Does female genital mutilation/cutting/ FGM/C) affect women’s sexual functioning? A systematic review of the sexual consequences of FGM/C. Sex Res Soc Policy. 2012;9(1):41-56. 29. Alsibiani SA, Rouzi AA. Sexual function in women with female genital mutilation. Fertil Steril. 2010;93(3):722-724. 30. Catania L, Abdulcadir O, Puppo V, Verde JB, Abdulcadir J, Abdulcadir D. Pleasure and orgasm in women with female genital mutilation/cutting (FGM/C). J Sex Med. 2007;4(6): 1666-1678. 31. Essén B, Sjöberg NO, Gudmundsson S, Östergren PO, Lindqvist PG. No association between female circumcision and prolonged labour: a case control study of immigrant women giving birth in Sweden. Eur J Obstet Gynecol Reprod Biol. 2005;121(2): 182-185. 32. Behrendt A, Moritz S. Posttraumatic stress disorder and memory problems after female genital mutilation. Am J Psychiatry. 2005;162(5):1000-1002. 33. Almroth L, Almroth-Berggren V, Hassanein OM, et al. Male complications of female genital mutilation. Soc Sci Med. 2001; 53(11):1455-1460. 34. Rouzi AA, Rouzi MB. Urinary catheterization and female genital mutilation. CMAJ. 2013;185(3):235. 35. Rouzi AA, Sahly N, Bahkali N, Abduljabbar H. Retraction technique for urinary catheterization of women with female genital mutilation. Eur J Obstet Gynecol Reprod Biol. 2013;169(2): 296-298. 36. Fazari AB, Berg RC, Mohammed WA, Gailii EB, Elmusharaf K. Reconstructive surgery for female genital mutilation starts sexual functioning in Sudanese woman: a case report. J Sex Med. 2013;10(11):2861-2865. 37. Foldès P, Cuzin B, Andro A. Reconstructive surgery after female genital mutilation: a prospective cohort study. Lancet. 2012;380(9837):134-141. 38. Colombo C. “L’articolo 583 bis c.p. un illecito compiuto in nome della religione?” Rivista di Criminologia, Vittimologia e Sicurezza, Vol. III - N. 2 - Maggio-Agosto 2009:60-67 39. Argo A, Averna L, Triolo V, Francomano A, Zerbo S. Validity and credibility of a child’s testimony of sexual abuse: a case report. Euromediterranian Biomed J. 2012;7:97-100 40. Argo A, Cucinella G, Calagna G, et al. Daphne II - Ve.R.S.O project: a new protocol for the management of sexual assault victims. Int J Gynaecol Obstet. 2012;24(4):141-153. 41. Argo A, Zerbo S, Triolo V, et al. Legal aspects of sexually transmitted diseases: abuse, partner notification and prosecution. G Ital Dermatol Venereol. 2012;147(4):357-371. 42. D’Amato S, Pompa MG. Aspects of the Italian legislation related to HIV testing. Ann Ist Super Sanita. 2010;46(1):51-56. 43. Prestileo T, Argo A, Triolo V, Zerbo S, Procaccainti P. Informed consent to perform the HIV diagnostic test: how to behave when minors are involved. Infez Med. 2008;16(4):200-203.

AL

9.

N

8.

SO

7.

R

6.

PE

5.

R

4.

Schoen EJ, Female circumcision. N Engl J Med. 1995;332(3): 188-189, author reply 189-190. Toubia N. Female genital mutilation: a call for global action. New York: women, Ink; 1993. Ashimi AO, Amole TG. Perception and attitude of pregnant women in a rural community north-west Nigeria to female genital mutilation. Arch Gynecol Obstet. 2015 Mar;291(3):695-700. Rushwan H. Etiologic factors in pelvic inflammatory disease in Sudanese women. Am J Obstet Gynecol. 1980;138(7 Pt 2):877-879. Berg RC, Denison E. A tradition in transition: factors perpetuating and hindering the continuance of female genital mutilation/cutting (FGM/C) summarized in a systematic review. Health Care Women Int. 2013;34(10):837-859. United Nations Children's Fund (UNICEF) Female genital mutilation/female genital cutting: a statistical exploration. New York, NY: Author; 2005a. Banks E, Meirik O, Farley T, Akande O, Bathija H, Ali M; WHO study group on female genital mutilation and obstetric outcome. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet. 2006;367(9525):1835-1841. Elgaali M, Strevens H, Mårdh PA. Female genital mutilation – an exported medical hazard. Eur J Contracept Reprod Health Care. 2005;10(2):93-97. Allam MF, de Irala-Estévez J, Fernández-Crehuet Navajas R, et al. Factors associated with the condoning of female genital mutilation among university students. Public Health. 2001; 115(5):350-355. WHO Technical Working Group. Female genital mutilation. Geneva: WHO, 1996. Kaplan A, Forbes M, Bonhoure I, et al. Female genital mutilation/cutting in The Gambia: long-term health consequences and complications during delivery and for the newborn, International. J Womens Health (Larchmt). 2013;5:323-331. Vissandjée B, Kantiébo M, Levine A, N’Dejuru R. The cultural context of gender, identity: female genital, excision and infibulation. Health Care Women Int. 2003;24(2):115-124. Powell RA, Leye E, Jayakody A, Mwangi-Powell FN, Morison L. Female genital mutilation, asylum seekers and refugees: the need for an integrated European Union agenda. Health Policy. 2004;70(2):151-162. Toubia N. Female circumcision as a public health issue. N Engl J Med. 1994;331:712–716. Iavazzo C, Sardi TA, Gkegkes ID. Female genital mutilation and infections: a systematic review of the clinical evidence. Arch Gynecol Obstet. 2013;287(6):1137-1149. Ghosh M, Rodriguez-Garcia M, Wira CR. Immunobiology of genital tract trauma: endocrine regulation of hiv acquisition in women following sexual assault or genital tract mutilation. Am J Reprod Immunol. 2013;69(Suppl 1):51-60. Teufel K1, Dorfler DM. Female genital circumcision/mutilation: implications for female urogynaecological health. Int Urogynecol J. 2013;24(12):2021-2027. Dirie MA, Lindmark G. The risk of medical complications after female circumcision. East Afr Med J. 1992;69(9):479482. Nour NM. Female genital cutting: clinical and cultural guidelines. Obstet Gynecol Surv. 2004;59(4):272-279. Teufel K. Gesundheitsfolgen von weiblicher Beschneidung: Eine Pilotstudie in Österreich [Health effects of female genital mutilation. A pilot study in Austria]. Diploma thesis, Medical University of Vienna, 2012. Agugua NEN, Egwuatu VE. Female circumcision: management of urinary complications. J Trop Pediatr.

FO

3.

© 2015 Wichtig Publishing

Vella et al

159 prod Biol. 2013;168(2):195-198. 48. Varol N, Fraser IS, Ng CHM, Jaldesa G, Hall J, Varol N1, Fraser IS, Ng CH, Jadesa G, Hall J. Female genital mutilation/cutting: towards abandonment of a harmful cultural practice. N Z J Obstet Gynaecol.2014;54(5):400-405. 49. Caroppo E, Almadori A, Giannuzzi V, Brogna P, Diodati A, Bria P. Health care for immigrant women in Italy: are we really ready? A survey on knowledge about female genital mutilation. Ann Ist Super Sanita. 2014;50(1):49-53. 50. Jacoby SD, Smith A. Increasing certified nurse-midwives’ confidence in managing the obstetric care of women with female genital mutilation/cutting. J Midwifery Womens Health. 2013; 58(4):451-456.

FO

R

PE

R

SO

N

AL

U

SE

O

N

LY

44. Kaplan A, Hechavarría S, Bernal M, Bonhoure I. Knowledge, attitudes and practices of female genital mutilation/cutting among health care professionals in The Gambia: a multiethnic study. BMC Public Health. 2013;13(1):851. 45. Ashimi A, Aliyu L, Shittu M, Amole T. A multicentre study on knowledge and attitude of nurses in northern Nigeria concerning female genital mutilation. Eur J Contracept Reprod Health Care. 2014;19(2):134-140. 46. Johnson OE, Okon RD. Perception and practice of female genital cutting in a rural community in southern Nigeria. Afr J Reprod Health. 2012;16(4):132-139. 47. Relph S, Inamdar R, Singh H, Yoong W. Female genital mutilation/cutting: knowledge, attitude and training of health professionals in inner city London. Eur J Obstet Gynecol Re-

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