Medical Videos ppt and Lecture Notes: Aug 28, 2011

01 September 2011

Female Genital Cutting

Female Genital Cutting
By:Safa Magid

Female Genital Cutting(FGC)
* Also known as: female circumcision & female genital mutilation
* Female circumcision is the term preferred by cultures who practice this custom

FGC -Definition
* Procedure involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious, or other non-therapeutic reasons.

WHO Classification of FGC
* Type 1: Excision of prepuce w/ or w/o excision of all of the clitoris
* Type 2: Clitoridectomy and partial or total excision of labia minora
* Type 3: Infibulation, includes removing all or part of ext. genitalia and re-approximation of remnant labia majora, leaving a small interoitus for passage of urine and menstrual blood

* Type 1 and Type 2 are the most common forms
* Type 1 and Type 2 account for 80% of the cases
* Infibulation accounts for 15% of the cases

FGC
* Currently ~ 130 million women and girls have had the procedure
* An estimated 2 million girls worldwide are at risk per year

FGC in the US

* Data from 2000 census suggests:
228,000 women and girls are with or at risk for FGC in the United States
* CA, NY, and MD have the most female immigrants and refugees from countries where FGC is prevalent.
* Occurs mostly in 28 sub-Saharan African countries
* FGC is practiced by Christians, Muslims, and adherents to traditional African religions
* Also practiced in Middle East and Asia

Origins and History
* Origins remain unclear
* FGC practiced in Pre-Islamic Arabia, ancient Rome, and Tsarist Russia
* Female circumcision was discovered in ancient Egyptian mummies in 200 B.C.
* Practiced in the United States until the 1970’s to tx hysteria, lesbianism, and erotomania

FGC and Religion
* Christianity:
FGC is not an obligatory religious requirement
* Islam:
FGC is not an obligatory religious requirement

FGC-Procedure
* Performed between the ages of 5-10, or prior to marriage
* Performed by a member of community who is not a healthcare worker
* Often performed w/o anesthesia
* However in metropolitan areas the use of anesthesia is more common

FGC Procedure
* Performed w/o surgical instruments. Razor blades or other instruments which may or may not be sterile are used
* Depending on socio-economic factors FGC may also be performed in a health care facility by qualified health personnel
* WHO is opposed to medicalization of all types of female genital mutilation.
* Reasons currently practiced:
o Rite of passage to womanhood
o Maintains chastity
o Ensure marriageablity
o Belief that it improves hygiene
o Social pressure to adhere to custom
o Belief that it is a religious requirement

Complications
* Prevalence of complications is unknown
* Rate of complications increase with severity of procedure( i.e. women with type III have > complications that women w/type I)
* A study of 120 Somalian women suggests rate of complications are inversely proportional to the age of the child when FGC was performed
* Women who had FGC btwn the ages of 5-8, had more complications than their 9-12 y.o counterparts
* Long and short term complications
* Some women with FGC do not experience complications

Short term complications
* Hemorrhage
* Severe pain
* Shock
* Infection
* Urine retention
* Ulceration of genital region injury to adjacent tissue
* HIV?-Possibly transmitted due to use of unsterilized equipment

Long Term Complications
* Cysts and abscesses
* Post-partum fistulaes: vesico-vaginal
* Keloid scar formation
* Damage to the urethra resulting in urinary incontinence
* Dyspareunia and sexual dysfunction
* Infertility
* Difficulties with labor.

Case Report

* 16 y.o female presents w/severe dysmenorrhea
* PE revealed the absence of a clitoris and fused labia majora with a 1cm opening
* Physicians initially thought pt had corrective surgery for ambiguous genitalia
* Later determined that while visiting Africa with her mother she had FGC performed
* Perinealography revealed:
o Filling of the vagina,urethra, and bladder simulating a urogenital sinus.
o Dilated vagina suggested obstruction
Perinealography

Case Report
* Defibulation procedure was performed
* The patients symptoms of dysmenorrhea eventually resolved

FGC and Obstetric outcomes
* WHO Study

FGC & Length of maternal hospital stay
* FGC and length of maternal hospital stay
o FGC Type I- RR: 1.15
o FGC Type II-RR:1.51
o FGC Type III-RR:1.98

FGC and Mental Health
* Anxiety
* Depression
* PTSD
* Feeling of incompleteness

Defibulation
* Corrective procedure
* Involves division of the fused labia majora with suturing of each labia for hemostasis
* Thus the infibulated scar, which is a flap obstructing the introitus and urethra, is removed
* WHO Indications for defibulation:
* Urinary retention
* Recurrent UTI’s or kidney infections
* Dysmenorrhea
* Dyspareunia or apareunia
* Prior to coitus
* Prior to labor
* It is also reasonable that defibulation can be performed to alleviate any mental health consequences for women who do not meet the WHO indications

Approach to patients with FGC
* Some physicians remain unfamiliar w/FGC & have expressed their shock during PE
* Some women report being reprimanded by physicians for having the procedure done
* Despite the fact the majority had FGC while they were children and were not given a choice

Patients perspective of FGC
* Many pts w/FGC who have immigrated to the West do not feel as if they abused
* Some feel that FGC was done “for them” and not an attack against them

Patients perspective of FGC
* 1st generation pts born in the West who had FGC while traveling abroad often have very different views than their foreign born counterparts
* HC workers may need to modify their approach depending on the pts perspective

Legality of FGC
* U. S. passed a law in March 1997:
* Made performing any medically unnecessary surgery on the genitalia of a girl younger than 18 years of age a federal crime.
* Reinfibulation was not included as a federal crime, so it may be performed with absorbable sutures in a running fashion if a woman chooses the procedure

Resources for pts and HC providers
* African’s Women’s Health Center
o Established in 1999 by Dr. Nawal Nour a Sudanese-American OB/GYN
o Goal of clinic is to provide culturally appropriate holistic care to African women who are refugees who may or may not have undergone FGC
o Defibulation is performed at this clinic

Resources for pts and HC providers
* WHO
* Website with information about FGC
* Includes fact sheet about FGC and guidelines for healthcare workers
* http://www.who.int/topics/female_genital_mutilation/en/
* http://www.who.int/reproductive-health/publications/rhr_01_18_fgm_policy_guidelines/index.html

Dedicated to all of my sisters who have had FGC.
To those who have suffered physical or mental consequences, I am inspired by your courage and strength.

References
Female Genital Cutting.ppt

Maple syrup urine disease Presentations

Maple syrup urine disease (MSUD) is a metabolism disorder passed down through families in which the body cannot break down certain parts of proteins. Urine in persons with this condition can smell like maple syrup.

Maple syrup urine disease (MSUD) is caused by a gene defect. Persons with this condition cannot break down the amino acids leucine, isoleucine, and valine. This leads to a buildup of these chemicals in the blood.

In the most severe form, MSUD can damage the brain during times of physical stress (such as infection, fever, or not eating for a long time).

Some types of MSUD are mild or come and go. Even in the mildest form, repeated periods of physical stress can cause mental retardation and high levels of leucine.