The Prevalence of Female Genital Operations

in the Houston Metropolitan Area

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Journal Article -- December 2000

By Misha F. Haque and Baruch A. Brody, PhD

This study explored the prevalence of female genital operations (FGOs), also known as female circumcision, among women in the Houston metropolitan area. The medical ramifications of the procedure and the specific type of procedure undergone were examined as well as the nationality and religious background of these women and their views regarding their experience.

To gather these data, we sent a questionnaire to practicing obstetrician-gynecologists in Harris County. This survey yielded a response rate greater than 36%, of which approximately 30% of physicians reported treating patients with FGOs at some time in their practice.

The results of this study demonstrate that a notable proportion of women in Houston, particularly those of African background, have experienced an FGO of some type and, accordingly, our obstetrician-gynecologists and primary care physicians clearly need to be aware of this cultural practice among their patients. 

Introduction

Female circumcision, referred to as female genital operations (FGOs) in this article, is an ancient traditional practice that has somewhat cryptic origins but has been traced back to the Pharaonic kingdoms of Ancient Egypt from as early as 200 BC (1). In recent years, FGOs have attracted international attention and have drawn much criticism from both the Western world and from within countries in which the practice actually occurs. To date, FGOs are estimated as affecting more than 130 million females throughout the world (1). Misconceptions about these procedures abound. Attempts to study the actual issues and concerns surrounding FGOs are crucial to understanding this phenomenon both overall and specifically as a medical concern.

The question of the prevalence of patients in the Houston metropolitan area who have undergone FGOs is intriguing as well as timely. Before recent mass immigration, which has made the "global village" phenomenon a reality, many foreign cultures remained exactly that -- foreign. However, most major cities in the United States are being exposed now to widely different cultures and ethnicities as a result of the large numbers of immigrants to these areas. The US Department of Health and Human Services estimates that in 1990 approximately 168,000 females in the United States had undergone or were at risk for FGOs (2). This includes immigrants from regions that traditionally practice female circumcision. Of these 168,000 females, 77% lived in only 12 states: California, Florida, Georgia, Illinois, Maryland, Massachusetts, New Jersey, New York, Ohio, Pennsylvania, Texas, and Virginia. In addition, 45% lived in metropolitan areas including Atlanta, Boston, Chicago, Dallas, Houston, Los Angeles, New York, Oakland, Philadelphia, and Washington, DC (2). In fact, according to the 1990 US Census, 13.2% of Houston's population is foreign-born; the Houston metropolitan area is the sixth greatest magnet among metropolitan areas in the country for new immigrants (3). Based on these statistics, Houston-area obstetrician-gynecologists are possibly seeing a notable number of patients who have had FGOs. Physicians and other health care workers must be able to provide medical care to a diverse population. To treat a population optimally, a physician must understand various cultures' practices and beliefs, including those of FGOs.

FGOs are a prime example of a cultural practice that has potentially great medical implications. As would be expected, immigrants carry culture and traditional practices, including the FGO, to their new homes. The goal of this research project was to discover how many obstetrician-gynecologists in the Houston area have encountered patients who have undergone some type of FGO and the experiences resulting from their exchanges, including information about patients' views, their areas of origin, and any medical complications stemming from the procedures.

Learning about this ancient cultural practice and other similar cultural phenomena will be crucial in improving physicians' overall treatment of various immigrant populations. Such knowledge can only serve to enrich our understanding and awareness of cultural differences.

Methods

The method of investigation used was a two-page questionnaire along with an additional response sheet if more than one patient with an FGO had been seen by a physician. An explanatory letter was enclosed with the questionnaire as well as a stamped, self-addressed envelope for return of the completed surveys.

The questionnaire asked the following: whether the physician had ever seen a patient with an FGO; how he or she would describe the anatomic appearance of the procedure; what, if any, medical or psychological complications stemmed from the procedure; what reason(s) were given for undergoing the FGO (if known); what opinion or emotion the patient had regarding her experience; what were the patient's country of origin and religion; what trends the physician may have noticed regarding nationality, education level, and length of time in the United States (if the physician had seen multiple patients); and if the doctor had received any requests to perform such a procedure on a patient or family member of a patient. If in his or her practice a physician had seen more than one patient with an FGO, an "additional response" sheet was provided for answers to these questions for each additional patient who had been seen. This additional response sheet could be photocopied as needed for each additional patient seen, as explained in the letter enclosed with the questionnaire.

Questionnaires were sent to all Houston area obstetrician-gynecologists listed in the Harris County Medical Society Membership Roster for 1998. Of the total of 353 questionnaires mailed, 125 physicians responded by mail, 0 by e-mail, and 3 by telephone (message stating interest left on pager voice mail), for an overall 36.3% response rate. Of the 125 physicians who returned the survey, 38 (30.4%) reported seeing patients with some type of FGO.

The variable level of responses received by mail was notable. Some questionnaires were incompletely answered, and often the additional response sheets for patients were not completed, leading to discrepancies in the numbers of patients recorded in the data collection.

The number of patients and number of physician responses in the accompanying tables of data do not correlate in all cases. Some physicians had seen more than one patient with an FGO but did not complete the additional response sheets provided for each additional patient seen. Therefore, each particular patient may not have a corresponding response for each question in the survey. Also, numbers are not the same from table to table because of incomplete responses to surveys and ambiguities in physicians' responses.

Results

We received responses from 125 physicians by mail; no responses were excluded. Overall, 38 of 125 physicians (30.4%) had seen at least one patient with an FGO of some type (Table 1). The question concerning the number of patients seen raised several ambiguities in the responses, including the responses of "several" (patients seen with FGOs), which do not specify exactly how many patients this implies. Of the 38 physicians who stated they had seen FGOs in their practice, 19 (50%) reported seeing one patient in their practice, and the rest had seen from 2 to 15 patients with FGOs at some point in their careers.

Most respondents did not answer the question of their patients' religion; of those who did answer, only 10 of 28 (36%) actually knew the religion. Out of 28 respondents who answered the question, 18 (64%) said the patient's religion was "unknown." The religion mentioned most often was Islam, with 7 of 28 (25%) of respondents stating their patients with FGOs were Muslim. Generally, FGOs are practiced in predominately Muslim countries and are often said to be linked to the religion, but actually no concrete evidence exists that Islam recommends or even condones the practice (4). FGOs were practiced long before the advent of Islam, dating back to the Pharaonic kingdoms of Egypt according to some accounts (1). Therefore, culture appears to have been widely responsible for the propagation of this traditional practice in countries throughout Africa and parts of the Middle East.

Many physicians did not answer the question concerning patients' reasons for undergoing an FGO, presumably because they did not ask why their patients underwent or advocated the procedure. Out of the 21 answers received to this question, culture was the most commonly cited (10 of 21 [48%]) reason for undergoing an FGO. Religion was not very frequently cited (2 of 21 [10%]) as a reason, but religion and culture are often intermixed and many people do not distinguish between the two in their daily lives, especially in the more traditional societies. "Tradition/social norm" was also infrequently given as a response (2 of 21 [10%]), possibly also because the lines are indistinct among the three entities (culture, religion, and tradition/social norm). Four of 21 (19%) responded that the FGO was "performed in childhood/no choice in matter" or that the procedure was done "at the insistence of a father or mother." The three patients from the United States included in the study gave varying reasons: one claimed that the procedure was done for redundant labia minora, a medical reason; the two other patients believed the FGO would enhance sexual responsiveness.

The surveyed group was questioned also about the types of FGO that were seen in the patient population. The most frequently noted (11 of 38 [28.9%]) type of FGO was "infibulation" (see definition in Table 2). The next most common was the clitoridectomy, a less radical procedure. Excision of the labia minora and clitoris, a "middle-range" FGO between infibulation and clitoridectomy, was noted often as well.

Interestingly, infibulation was the most commonly seen procedure in this survey; in the countries mentioned, infibulation is traditionally the most common type of FGO performed. Women of African origin, who make up the overwhelming majority of this survey, had the most FGOs overall. Out of the African countries mentioned, Nigeria was the most common country of origin (10 of 46 [21.7%]) and, accordingly, correlated directly with the number of infibulation cases. Of the 46 responses, Somalia accounted for 9 (19.6%); Sudan, 6 (13%); and Ethiopia, 5 (11%). Liberia, North Africa, Senegal/East Africa, Uganda, and the "Middle East" each were mentioned in 1 (2.1%) of the responses. A significant number (8 of 46 [17%]) of responses indicated that a patient was "African," but the specific country or region was not identified. Based on this survey, the geographical breakdown of areas from which patients with FGOs come does correlate generally with the worldwide incidence of FGOs, as most are carried out in African countries with a very small minority performed in the Middle East and parts of Asia (2).

The given responses did demonstrate varied medical and psychological complications with no single striking common problem seen overall. Of possible complications resulting from the FGO, sexual dysfunction caused by both mental and physical trauma seemed to be the most common complaint (Table 3). Scarring, small introitus, inability to achieve orgasm, and extensive peripartum periurethral lacerations were among the frequently mentioned complications of FGOs. Vaginismus was reported often as well as inability to achieve orgasm or enjoy intercourse. In many of the traditional societies that practice FGOs, the operations are used as a supposed "safeguard" in keeping women chaste; the thinking is that if women do not enjoy sexual activity, they will be unlikely to participate willingly (and unlawfully) in it.

Most patients did not express any emotion to their physicians about their experience with FGOs. This may be a result of only short-term interaction between the physician and patient, in which the patient may not yet be comfortable discussing such a private issue. Cultural norms may also play a role; women in traditional societies are often taught to keep their difficulties and complaints to themselves and withhold their feelings. Discussing problems related to sexual function with anyone, especially a relative stranger such as a physician, may be considered shameful. Of the 29 responses to this question concerning patients' emotional responses to FGOs, 10 (34%) were noted as "no emotion expressed," and "anger" was the next most common response (6 [21%]). Only approximately 2 (7%) of the patients felt that the FGO "was a 'normal' part of life." Three women (10%) felt "embarrassment" about the procedure, 2 (7%) wished that they had never undergone an FGO, and 2 (7%) did not want to discuss the issue with their physicians. Unhappiness, concern about sex life, and "acceptance" of the FGO each netted 1 (3%) response. One patient's husband (3%) was vehemently opposed to the procedure. 

Discussion

This research project attempted to discover the current prevalence of FGOs in the Houston metropolitan area. Approximately 350 obstetrician-gynecologists in the Houston area were sent questionnaires asking how many patients, if any, they had seen with FGOs over the course of their practices in Houston. The survey yielded 125 (36%) responses. Of these respondents, 38 (30.4%) had seen at least one patient with some type of FGO in their practice. The most common types of FGOs seen were infibulation and clitoridectomy. Most of the 46 patients with FGOs were of African origin, most commonly Nigerian (10 [21.7%]) and Somalian (9 [19.6%]). Scarring and sexual dysfunction were among the complaints mentioned most frequently by these patients; responses to the medical and psychological consequences of FGOs were fairly evenly distributed without a clear majority for any particular answer. The religion of the patients was unknown in most of the survey responses, but of those in which religion was known, Muslims made up the majority (7 of 28 patients [25%]) with FGOs. Culture was the major reason given by 10 of 21 patients (48%) for having an FGO. Overall, 10 of 29 (34%) had "no emotion" about the FGOs they experienced. Of those who did express emotion, "anger" was the most common response.

This study had several limitations. First, the results were somewhat difficult to interpret in a substantial number of responses because of the open-ended nature of the questions, which resulted in a less accurate data collection as ambiguous responses were harder to include under larger groupings. The survey forms were also inconsistently completed; multiple forms were sent in case a physician had seen more than one patient with an FGO, but these forms were often not filled out in these cases. Also, the results of this study are applicable only to the Houston area and to extrapolate any wide-range conclusions from this study would be difficult due to the geographic limitations. Another limitation in the design of the study was the method of finding the physicians to answer the questionnaire; the Harris County Medical Society Membership Roster was used, which may have excluded some obstetrician-gynecologists in the area.

The implications of this research may be quite significant within the state of Texas. Houston represents one of the most diverse cities in the country; as a result, the medical and health care concerns of its population are just as varied. Many parts of Texas are as diverse as the Houston area: Dallas-Fort Worth, Austin, and San Antonio. Patients with FGOs probably live in these cities as well. These patients are unique in a physician's practice as they may require specialized medical care as well as careful attention to psychosocial and cultural issues that affect their well-being. The needs of these patients should be recognized and incorporated into the management of their health. Just as the Hispanic population is now known by doctors to have a higher incidence of diabetes in its general population (5) and the African American population has been noted to have a propensity for hypertension in its general population (6), the African and Middle Eastern patients in our country should be recognized for their unique health care needs -- specifically, for physicians to be aware of women who have undergone FGOs and to be able to treat them in a medically and socially appropriate manner.

To this end, the call for educational programs to expand understanding in this little-explored realm is great. Workshops could be arranged for physicians of various specialties. The origin and cultural basis of FGOs could be explained and discussed, along with specific medical findings in patients with the procedures and treatment plans with a multidisciplinary focus (ie, psychosocial as well as medical/surgical treatment). The American College of Obstetricians and Gynecologists has responded to this developing need and has recently published a manual and slide presentation that discusses the clinical management of circumcised women (7). The potential is great for learning, as is the potential for bettering the patient's experience and outcome through our education and compassion.

Ms Haque, fourth-year medical student, and Dr Brody, director, Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Tex. Send reprint requests to Ms Haque, 4807 Pin Oak Park Dr #3312, Houston, TX 77081; email  mh692106@bcm.tmc.edu .

 

Table 1. Number of patients seen with any type of female genital operation (FGO).
No. of Patients Seen No. of Physicians*
1 19
2-4 12
5-6 1
10-15 2
2-3/y 1
"Several" 3
 
* Of 125 physicians who responded, 38 had seen at least one patient with an FGO. Two physicians had not seen patients with an FGO. One physician had patients who had left an African country to keep their children from undergoing the procedure, and another received a request to perform the procedure (which was denied and replaced with education).
   
Table 2. Types of female genital operations seen by surveyed physicians.
Type of FGO No. Seen
Hood of clitoris removed 2
Clitoridectomy 10
Clitoral hood and part of labia minora removed 1
Excision of labia minora   1
Excision of labia minora and majora 1
Excision of labia minora and clitoris  6
Fused upper labia minora 1
Fused anterior and partial posterior labia* 2
Clitoridectomy and fused labia*   2
Partial labiectomy† 1
Narrowing of vulva 1
Scarring/banding of vulva 1
Scarring in periurethral area  1
Infibulation‡   11
"Destructive" appearance 2
"Normal" appearance 1
   
* These responses did not specify labia minora and/or labia majora.
† This respondent noted that the procedure was done for redundant labia minora, which caused the patient significant medical problems including dyspareunia.
‡ Infibulation refers to removal of the clitoris, labia minora, and labia majora with sewing together of the remaining tissue to allow only pinpoint passage of menstrual blood and urine.
   
Table 3. Complications resulting from female genital operations.
Type of Complication No. of Patients
Keloid scarring 1
Scarring  3
Scarred introitus 1
Tight introitus 1
Introitus too small for penetration/unable to have sex 3
Coitus uncomfortable 2
Inability to achieve orgasm 3
Complete narrowing of vulva 1
Periurethral laceration (extensive) at delivery 3
Vaginismus 1
Pelvic pain 1
Infertility   1
Severe pain during female genital operation 1
Psychological problems 1
Discomfort of sexual partner 1

Acknowledgments
The authors gratefully acknowledge Delores D. Smith for her extensive assistance during the research and writing of this article.

References

  1. El Dareer A. Woman, Why Do You Weep? London: Zed Press; 1982.
  2. Hedley R, Dorkenoo E. Child Protection and Female Genital Mutilation: Advice for Health, Education, and Social Work Professionals. London: Forward; 1992.
  3. The Immigration and Naturalization Service. Houston Metropolitan Area Immigration. Accessible at  http://www.fairus.org/html/msas/042txhou.htm. July 6, 1999.
  4. The Koran Interpreted . New York, NY: MacMillan; 1955.
  5. Balasubramanyam A, McKay S, Nadkami P, et al. Ethnicity affects the postprandial regulation of glycogenolysis. Am J Physiol. 1999;277(5 pt 1):E905-E914.
  6. Tucker K. Dietary patterns and blood pressure in African Americans. Nutr Rev. 1999;57(11):356-358.
  7. Female Circumcision/Female Genital Mutilation: Clinical Management of Circumcised Women. Washington, DC: American College of Obstetricians and Gynecologists; 1999.

December 2000 Texas Medicine Contents
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