I placed the distal blade of the mayo scissors through the bean-sized opening at the bottom of her mutilated genitals. It was as though my patient’s bottom had been set on fire; her clitoris, clitoral hood, and labia were gone. Covering the vagina was a scar sewn together by the piercing of thorn needles and adhesions fused from the blunt pounding of primitive instruments.
I was shocked, almost repulsed, the first time I examined her. Struggling to maintain professional distance, I asked her to tell me her story. The mutilation had been performed by a grandmother, aunts, and other female tribal authorities. The ritual had never been explained to her. She knew when it was over she would look like rest of the women in her community. I wondered how many other girls she had witnessed going through this rite of passage. My patient had suffered extensive cutting. Following her initiation, she was unable to urinate. The covering scar dammed back her urine until it filled her vagina. When the pressure became painful she found a position that allowed urine to trickle from the small opening closer to her rectum than her urethra. She lost consciousness.
This patient was brought to my by her cousin, a Nigerian dentist, who had avoided the ritual by being born to an educated family living in the capital city. Wearing colorful silk gowns and traditional headdresses the women carried themselves with elegance when they entered the office. I had been caught off guard when the dentist told me what her relative had suffered.
In an attempt to be supportive, the dentist sat in a chair in the dressing area of the exam room. She chatted about her own baby, whom I had delivered just a few years earlier. Her labor had been uneventful; the boy was doing well. I wondered what it had taken to convince her cousin to come here, to come to my office.
Already thirty weeks pregnant my patient was frightened by the thought of the pain and trauma of delivery. I couldn’t imagine the pain this patient experienced when impregnated despite disfiguration and scarring. She asked what would happen. They both knew about hemorrhaging and infections that often followed these deliveries. During her exam, I took mental pictures so I could study methods of reconstruction, which technique might provide the best result. Later I researched articles describing step-by-step protocols.
As my patient dressed and left the exam room for consultation, I looked up the World Health Organization’s classifications of female circumcision in order to categorize my patient’s condition. I felt that by placing her in the formula of scientific terminology I could maintain that professional distance doctors are trained to create. Making her a case, or a diagnosis, eased the awfulness of her condition. I put her in a textbook.
The classifications begin with “least extreme” and progresses to “most extreme.” In summary the bulletin read:
Type 1: The foreskin of the clitoris is split exposing the glans. A clitoridectomy is then performed.
Type 2: The labia minora are partially or totally removed.
Type 3: The total excision of the clitoris, both the labia minora and majora, and the fusions of the right and left vulva over the vagina, sewn with thread or secured with other items like thorns. A small, pencil-size hole is left to allow passage of menstrual blood and urine.
But the classification was not complete. A fourth type was added for practices not covered:
Type 4: All forms of cutting not described in types 1-3 such as: pricking, piercing, or incision of the clitoris and/or labia; stretching of the clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue; introduction of corrosive substances into the vaginal vault.
The words did not work. The language lied. How could one mutilation be less extreme, another more? To say less extreme made one seem more fortunate than another. Using scientific nomenclature allowed professional space but left me ill-prepared for physical exam and development of a care plan. The act of mutilation is dehumanizing; to discuss it using the medical lexicon sanitizes the evil. The term female circumcision was coined so cultured people could more politely converse in public forums. I was angered by the idea of sanitizing the violation with censored words. I couldn’t get the picture out of my mind.
I tried to rationalize my personal and cultural judgments by remembering that genital mutilation was practiced in the United States until the 1950s. Dr. John Harvey Kellogg, the medical director and chief of surgery at Battle Creek Sanitarium, was a major proponent of genital mutilation. The health institute he ran was attended by Presidents Taft and Harding, Mary Todd Lincoln, Sojourner Truth, Sarah Bernhart, Amelia Earhart, Henry Ford, Thomas Edison, Roald Amundsen, Richard Halliburton, and other notables who took the water cures from above and below. The Kellogg breakfast cereals were served. They were made without chemicals and salts thought to increase sexual stimulation. Dr. Kellogg dedicated himself to preventing masturbation and promiscuity (both male and female). When the diet didn’t work, hands were tied and metal cages placed when the children were put to bed; if these failed the knife was next. Dr. Kellogg’s tome reads:
A remedy which is almost always successful in small boys is circumcision. . . . The operation should be performed by a surgeon without administering an anesthetic, . . . pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment. The soreness which continues for several weeks interrupts the practice. . . . In females, the author has found the application of pure carbolic acid to the clitoris an excellent means of allaying the abnormal excitement.
Thousands of Australian schoolgirls were circumcised for the same reasons. Mutilation is a growing practice in Asia. Every continent, every culture has a history of mutilating women. Still, it is African women who suffer most. While the data varies, UNICEF estimates that over 130 million African women have been scarred.
The list of mutilation sequelae is long; vesico-vaginal fistula (opening between the bladder and vagina), dysuria (painful urination), chronic urinary tract infections, kidney failure, dysmenorrhea (painful periods), acute and chronic pelvic infections, infertility, sexual dysfunction, complications during pregnancy, chronic scar formations, life-long disabilities. The psychological trauma is poorly documented; post-traumatic stress disorder classifications seem insufficient.
The explanations for why this ritual of initiation continues to be carried out include a male desire to control female sexuality. Female relatives of grooms still inspect the bride before a dowry is given. The virginity test must be passed. There is also a belief that FGM reduces a woman’s desire for sex and prevents infidelity, promiscuity, and lesbianism. A “calming” occurs. Once a part of culture, the mutilation becomes an accepted ritual.
Often, unclean instruments are used in unsanitary conditions. The same glass, razor blades, knives, and piercing tools are used over and over again. Transmitted infections, including HIV, are common.
I tried to be sensitive in my discussions regarding female mutilation and the resulting conditions. My patient did not seem comfortable with any of the language. She expected me to know what had happened and how to take care of it. To some degree she reminded me of my most senior patients when they said, “There’s something wrong down there.” They are not interested in informed consent or alternative treatment options. Whatever it was, it needed to be fixed, preferably soon.
In labor, with an epidural, my patient was pain free and ready for me to attempt repair. I waited until the baby was close to delivery. The fetal vertex descended to a plus-one station. The scarring covering the vagina began to stretch. I thought it would be easier to control bleeding with the baby out and the worry of fetal distress or intrapartum hemorrhage gone.
I wondered how aggressive and heavy-handed, I would need to be in order to open the scarring. I hoped the covering would be paper-thin and that like Christmas wrapping it would separate by pressure, without opening and closing the scissors. I decided against using a scalpel because the blunt back of the scissor blade would not damage the vagina or urethra where the knife could slip deep into hidden tissue. It might mark the baby’s descending head.
My hopes for a delicate, tissue-sparing repair failed. The scarring was thick, thicker than shoe leather. I began to second-guess my choice of instruments.
I opened the injury starting near the anus and worked up toward the urethra and mons. The rugae of the vagina appeared laterally and then the anterior wall. I wondered how damaged the urethral meatus would be, if she would ever urinate without pain. As I opened the scarring around this area, I discovered that the hidden vaginal vault was intact. And then it was as though the urethra blossomed as I exposed it for the first time in many years. “Relief” was the only word that came to mind. I continued until there was no normal tissue to uncover. The clitoris had been totally destroyed.
I was surprised by the lack of bleeding. Few vessels supplied blood to the tissue. I ran a modified baseball suture along the edges of the repair and addressed the delivery. I avoided cutting an episiotomy. She didn’t need another trauma.
I lifted the baby up and placed her on her mother’s chest. After cutting the umbilical cord, I stepped back and observed the family bond. Aunt and mother talked to the baby in their native language. I assumed this baby would escape subjection to tribal custom, but did not ask.
When I made hospital rounds in the morning I found my patient sitting cross-legged on the bed. I knew the position was possible because the scarring was gone.
“Can you pee without pain?” I asked.
“Yes,” she said, “like a little girl.”