Dilemmas for women, and doctors, in addressing the effects of FGM
Ontario doctors grappling with how to treat women who as young girls were subjected to female genital mutilation are sometimes asked to reverse part of the procedure done a world away, provincial records show.
The process — surgically reopening the vagina — is called “repair of infibulations,” according to the Ministry of Health and Long-Term Care.
Infibulation is the clinical term for the surgical narrowing of the vagina that is one of several types of female genital mutilation (FGM) performed in 29 countries around the world, and sometimes seen as a rite of passage into womanhood or a condition of marriage.
Billing records submitted by Ontario doctors show the reversal surgery has been performed 308 times in the past seven years in Ontario, though it may be done more often and billed under a different code.
While repair of infibulation opens the vagina, there is no current procedure that replaces removed tissue.
Female genital mutilation refers to four different procedures done in countries including Somalia, Sudan, Egypt and parts of Southeast Asia, usually by a nonmedical practitioner.
This practice “damages the woman physically and emotionally,” says Dr. Joseph Daly, a gynecologist at St. Joseph’s Health Centre who has performed the reversal procedure numerous times.
“Women suffer needlessly from this procedure and there’s no clinical value in the procedure,” said Daly.
Type 1 FGM is removal of the clitoris; type 2 is excision of the clitoris and labia minora with or without the labia majora; and type 3, also called infibulation, is when the labia are cut and repositioned to seal shut the vagina, leaving only a small opening for urination and menstrual flow.
Under the Ontario Health Insurance Plan, doctors are paid $115 per reversal operation, called “deinfibulation.”
A Toronto woman in her mid-30s was subjected to female genital mutilation in Somalia when she was 4 years old, several years before she came to Canada with her family. She told her story to the Star on the condition that she not be identified.
She doesn’t recall having the procedure, but knows that it was done with anesthetic by a female “practitioner,” a friend of the family who was not a medical doctor but had experience doing this to girls.
Her mother told her she had to be sewn up twice. Girls who are infibulated have to stay in bed for weeks with their legs bound to allow the wounds to heal and prevent them from running around and ripping the stitches, she said. They’re taken to urinate and held over potties because they can’t squat at the Africanstyle toilets.
But she was active and refused to sit still, so her stitches came loose.
“The memories aren’t clear, but I know the second time was more traumatic,” she said. “I couldn’t use the bathroom myself. Peeing hurt. I remember being frustrated because I wasn’t able to be mobile anymore.”
Growing up in Toronto, thousands of miles away from her native home, she never thought about the fact that she had been subjected to the procedure, she said. Since most of her female peers also had it done before immigrating to Canada, it wasn’t shameful or taboo in her social circle.
Only Canadian physicians expressed alarm. “When they examined me they would say, ‘What’s wrong with this child?’ ” she said. “A lot of doctors weren’t aware of it. They kept questioning my family.”
Still, she said it wasn’t an issue as she became a young adult and began to date. She was a devout Muslim, and sexual activity was off-limits.
But since she was a teenager, she knew she would have the surgery to open her up before consummating her marriage.
Without a deinfibulation — or defibulation, as it is also sometimes called — to create a larger vaginal opening, intercourse could be impossible, or at least very painful.
“I didn’t want to feel the pain,” she said. “So why not take the easiest and least painful route?
After she got engaged to her husband, she thought more seriously about how she wanted to handle sex, she said. Her fiancé, raised in the western world, was on board with whatever she decided.
Some of her friends, also newly engaged or married, decided against having the procedure before they had sex for the first time.
“It depends on the girl,” she said. “It depends on her point of view. And it depends on how the husband views it and feels about it.”
She approached her family doctor, a female physician who worked with many Somali women. Her doctor didn’t react with alarm, but gave her a referral to a specialist, a local obstetrician-gynecologist.
He walked her through the surgery and alleviated her fears.
Cut and sewn up so young, she didn’t know what anatomic structures she was missing and what body parts needed to be — or even could be — reconstructed, she said.
“Would this surgery take my virginity? What can’t I have back and how much difference will that make in my sexual relationship?”
Doctors who perform the reversal surgery walk a tightrope fraught with cultural issues.
Daly says it helps that he has connections in the Somali community, and in others whose cultures may practise female genital cutting. Daly said the colour of his skin — he is Black — has been an advantage in making women from certain ethnicities feel comfortable to talk about the issue.
“There are not many of us around,” he said of Black gynecologists in the GTA. “Patients see me because of this.”
Recently, though, he said he hasn’t performed the surgery as often as he would predict for a population, especially in the GTA, that is home to many women emigrating from countries where female genital cutting is still the norm, or at least a common practice.
The Health Ministry data shows that, on average in Ontario, only about 40 repairs of infibulations are performed each year.
Rachel Spitzer, an OB/GYN at Mount Sinai Hospital and associate professor at the University of Toronto, said that the numbers seem “sur- prisingly low.”
She’s not aware of any information available that explains the motivations for women who seek — or do not seek — this type of surgery or identify those at risk.
“We lack information on the prevalence of women who arrive who have that done,” she said. “There’s no data to clarify.”
Spitzer performs a handful of repairs each year, she said, sometimes during childbirth in order to avoid an episiotomy or extensive tearing.
Other physicians refer these women to Spitzer, she said, because they aren’t familiar with the various types of female genital cutting or don’t know how to offer treatment. Fifty per cent of those referrals, Spitzer said, are women who have been infibulated and are candidates for surgery.
The other half is a mix of women with different types of genital cutting, or scarring on the vagina that doesn’t fit the classifications, she said.
Referring physicians may be unable to do a Pap smear, a routine screening test for cervical cancer, Spitzer said. Or they may have complications, complaining of urine dribbling, difficulty managing their periods, pain during intercourse or trouble experiencing pleasure during sex.
With every patient, Spitzer said she explains the limitations of surgery. She can make an opening large enough for a baby to get out, and make sex more comfortable, she said. She’ll sew tiny stitches to repair the damaged sides of the labia that were sewn shut. But there are currently no procedures Spitzer is aware of in Canada that can replace lost tissue, she said.
For all the women she treats, Spitzer said she tries to teach them about their bodies. “We talk about anatomy,” she said. “Sometimes we use a mirror to do that.”
Crista Johnson-Agbakwu, an obstetrician-gynecologist and director of the Refugee Women’s Health Clinic in Phoenix, Ariz., and a recognized expert on female genital cutting, said that a small number of patients don’t want to be opened to give birth because they are “staunchly proud” and believe it makes them beautiful.
Others, after a deinfibulation during childbirth, are “distressed” by the new appearance of their anatomy — they might think their labia are too long, for instance — and ask to be closed up.
Johnson-Agbakwu will not sew them back up, she said. But in those cases, she will do what she can to make the clitoral area look acceptable to them.
It is a Criminal Code offence to perform female circumcision in Canada, including to reinfibulate a woman — meaning to sew her back up.
A 38-year-old woman, who lives just outside Toronto, did not have the surgery when she got married.
She was subjected to FGM at the age of 7 in Sudan before immigrating to Canada in 2006, and she said she was only partially sewn up, leaving her a larger opening.
Nonetheless, she said, sex was painful at the beginning.
Back home in Sudan, she said, “closed-minded men” would brag about how many days it took to penetrate their wives, who were often stitched mostly shut. “They think if they open themselves they do an honour job,” she said. “They think: really good for them!”
For the mid-30s Toronto woman who had the surgery, she said she had pain in the days following the repair, a roughly 45-minute procedure. But she didn’t experience the “drastic, body-changing” event she expected.
For a time, she avoided public bathrooms because she thought her urine flow sounded different and strange, but she is happy with her new appearance. She knows she will never look like the average woman — and that suits her just fine.
“What’s done is done,” she said. “And I am happy with what I have. I am able to have a normal sexual life.”
After she recently had her first child, her own mother apologized for having subjected her to FGM. It came up during a conversation about how other Somalis send their children back to Africa to have the procedure.
She said nowadays, parents aren’t doing the extreme version, like what was done to her. They’re doing more of a “nick or pinprick.” She doesn’t object to the ritual being done on girls for religious reasons if it’s only to draw a bit of blood.
But she would never subject her daughters to FGM.
“Women suffer needlessly from this procedure and there’s no clinical value in the procedure.” DR. JOSEPH DALY ST. JOSEPH’S HEALTH CENTRE
Mount Sinai OB/GYN Rachel Spitzer performs a handful of surgeries each year to repair damage caused by female genital mutilation.
Dr. Joseph Daly says female genital mutilation “damages the woman physically and emotionally.”
Dr. Rachel Spitzer, an OB/GYN and University of Toronto associate professor, tries to teach her patients about their bodies, using a mirror.