On Reinfibulation: Part of the Female Genital Mutilation/Cutting Discussion that Rarely Gets Mentioned.

At a recent conference where I spoke about Female Genital Mutilation/Cutting (FGM/C), a colleague asked about the issue of reinfibulation. This comes up often. Before I explain what reinfibulation is, I need to briefly explain its necessary predecessors: FGM/C and ‘Deinfibulation’.

FGM/C is a practice that “comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons”. It is common in many parts of the world where around 2 million procedures are performed every year. According to UNICEF, more than 200 million girls and women have undergone that procedure so far in more than 30 countries.

Anatomically and physiologically there are different types of FGM/C, and the most severe form -- FGM Type III, or ‘infibulation’ -- involves cutting most of the external female genitalia and stitching together the ends, leaving only a small opening for urine and menstrual blood.

It does not take much to imagine how this procedure might affect a woman’s ability to undergo certain gynecological procedures (like a pap smear), have sex, or delivery a baby vaginally. In order for that to happen, the skin has to be cut open. This is called ‘defibulation’ or ‘deinfibulation’.

Across the US, obstetric practitioners – Obstetricians, Family Physicians, and Midwives -- encounter women who had undergone FGM/C and manage the long-term consequences of FGM/C, including deinfibulation.

This is where reinfibulation comes in. Reinfibulation is the re-suturing after delivery or gynecological procedures of the incised scar tissue resulting from infibulation. An accurate estimate of the prevalence of reinfibulation – overseas or in the US -- is difficult to obtain, but according to some studies, around 6.5-10.4 million women are likely to have been reinfibulated worldwide.

In the US and other immigrant and refugee-receiving countries, some women have anecdotally been known to request it, saying they feel “naked” if the area is left open and that they want to feel whole or go back to the way they looked before.

What’s the problem with that? That procedure is, in most cases, not medically necessary, and as such, may also constitute FGM/C in itself, leading some to view it as a form of “medicalized FGM”, as well as a violation of the medical code of ethics.

Against this, others consider the choice to “reinfibulate” a matter of patient autonomy, arguing that individual women have the right to express their traditional cultural preferences, and choose their own bodily modifications – especially when it means going back to the ‘only body they know’ and are used to. This tension emerged recently in a UK case (where reinfibulation is illegal), where a British physician was charged with FGM/C after he performed reinfibulation following a delivery. He was later acquitted.

While US state and federal laws prohibit FGM/C, there are currently no laws specifically addressing reinfibulation, leaving physicians without any clear guidelines about how to approach this issue in practice. In the UK, the Royal College of Obstetrics and Gynecology Clinical Guidelines state very explicitly that: “Re-infibulation is illegal; there is no clinical justification for re-infibulation and it should not be undertaken under any circumstances”. The Society of Obstetrics and Gynecology (SOGC) of Canada, in 2013 stated: “There is concern that female genital cutting continues to be perpetuated in receiving countries, mainly through the act of re-infibulation… Requests for re-infibulation should be declined”.

Other professional organizations are more nuanced in their language. The American Academy of Family Physicians (AAFP) in a 2015 policy statement says: “…the AAFP strongly cautions its members against performing reinfibulation”. The American College of Nurse Midwives, in a newly released position statement note: “Reinfibulation is considered a form of medicalized FGM/C and a violation of medical ethics. The risks of the procedure outweigh any perceived benefits”, but did not explicitly tell its members not to perform it. The American College of Obstetrics and Gynecology (ACOG) has no current guidelines on reinfibulation.

For clinicians facing this issue there are multiple technical, as well as ethical, questions to consider. From the clinical perspective: is there ever a medical rationale for this procedure? If so, is there a ‘best-practice’ on how to do it? How should clinicians counsel patients about reinfibulation in the context of US culture and law? What should clinicians do if their patients’ desires are at odds with their own beliefs about FGM/C? How might refusal to perform it affect the doctor-patient relationship?

Clinicians will have to tackle this on a case-by-case basis and consider their own beliefs and about FGM and its management in the adult patient, in consideration of patient autonomy, professional ethics, universal moral standards, and the vow to “do no harm”.

Clinicians should also ask themselves how is reinfibulation different from other – increasingly popular – cosmetic procedures on the female genitalia, such as vaginoplasty or labiaplasty? This may introduce uncomfortable truths about race, class and double standards. For example, is it OK for a white woman to have these types of surgeries – sometimes known as (yes) the “Barbie” labiaplasty with no repercussions (many, if not most, are done for “non-medical reasons”), whereas if a woman, say, from the Sudan, were to request a genital altering surgery, it is to be considered FGM?

Is it a clinician’s duty to ‘just say no’ because, inherently, FGM is illegal and a human rights violation? Or decline because the original intent for FGM/C is patently oppressive, and regards vaginal alteration, inherently, as a means of controlling women’s sexuality, and a means of “assuring” their chastity, virginity and fidelity?

Considering the increased interest in medicalized FGM/C because of the ongoing Michigan case, we must engage in this discussion as a profession. First, perhaps, amongst ourselves, possibly with the help of ethical-decision-making tools such as the A Framework for Ethical Decision Making, from Santa Clara University’s Markkula Center for Applied Ethics. Importantly, this is a discussion that should include our professional organizations, human rights and legal experts, and, critically, women affected by FGM/C themselves.

This article was informed by the collaborative research conducted with Rebecca Reingold JD, and Holly Hedley of the O'Neill Institute for National and Global Health Law; Kevin FitzGerald, S.J., PhD, PhD, at the Pellegrino Center for Clinical Bioethics; and Samantha Wu, BS, also from the Pellegrino Center for Clinical Bioethics, as part of a “Complex Moral Problems” Grant from Georgetown University.

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