I had deliberately delayed doing this piece for the simple reason that I do not want the persons involved in the narrative to easily identify with the saga. With current reality and the benefit of hindsight, one can safely refer to the period of occurrence as distant past. So, one feels comfortable to tell the story now.
It had come as an invitation to perform a Caesarian operation on a patient who has been in labour for the past 24 hours. As a routine, I had asked what was the indication for the procedure and my colleague had politely said: “Chief wait first, until we get there.” It was during the early hours of the day and not the best time for conversation. So we drove silently to his facility.
On arrival, the patient was already on the operating table. Examining a patient before a surgical operation is a conditioned habit among surgeons. And when I asked my colleague if I could go ahead and examine the patient, he had no objection whatsoever.
When I raised my head up after examining the patient, the stunned and curious expression on my colleague’s face was more intense than mine. He simply read me and said: “That is the indication for the Caesarian.”
The anatomy of the outer genital tract had been completely altered. The outer vaginal mould known as the labia majora and the inner fold known as the labia minora had been sliced off. In their position was a fleshy membranous scar tissue covering the vaginal introitus or rather opening. The disposition was such that the urethral orifice was covered by this membrane such that anytime she passed urine it flowed on the membrane and escaped from the back! She even took it as being normal.
Having seen that much, we immediately proceeded with the Caesarian Section, which went on uneventfully.
In our environment the outcome of female genital mutilations can vary from simply slicing off the clitoris to as severe as amputation of the Labia majora and minora. Infibulations, which involves the cutting off the labia and stitching the wound to further narrow the vaginal opening, is not commonly practiced in our environment. The pinhole nature of the vaginal opening makes penetration during sexual intercourse one hell of an exercise. Sometimes it takes days for the male partner to penetrate his partner’s vagina. In some extreme cases of Gynaetresia or vaginal introitus narrowing a traditional midwife may be invited to come and deinfibulate the bride. This of course is done secretly as the process is regarded as weakness on the part of the groom.
Of particular interest to us here is the gishiri cut practiced in the northern part of our country. This is/was considered as palliative or in some instance as a cure for some gynaecological challenges. The terminology gishiri is derived from salt. It was the name given to the long knife used by merchants to cut salt during transaction. The knife is simply inserted into the vagina and a cut made posterior towards the perineum. This has not been shown or proven to be of any medical benefit to the victim rather a high incidence of vesico vaginal fistula is the outcome in sizeable number of cases. This again is compounded by girl child marriages in the climes where the practice is acceptable.
There are other forms of genital mutilations known that are hoped would enhance fertility and sexual pleasure, like vaginal stretching where young girls are encouraged to start inserting sticks into their vagina before the age of puberty. In some culture, the vaginal introitus is scarred by inserting corrosive agents into it and in some extreme cases burning it. In this category of female genital mutilation can be added pricking, incising and nicking of the clitoris. The variety of this useless procedure depends on the instrumentalist as there is NO standard way of causing this discomfort. It must be made categorically clear here that there are no medical benefits attributable to female genital mutilation.
The procedure is fraught with a lot of complications, which could be of short term or long term incidence. For the short term complications: bleeding, swelling of the vagina, pains and wound infection could all be too common features. These could lead to anaemia with its antecedents, urinary tract infection, tetanus, vulva gangrene and necrotising fasciitis or flesh eating infection. Non-septic instrumentation could facilitate the transmission of Hepatitis B, Hepatitis C and human immunodeficiency virus HIV infection.
The long term complications would include vaginal stenosis or narrowing difficulties in urination. In our environment vesico-vaginal and recto-vaginal fistulae are very common especially in the northern part of the country. These are distressing holes connecting the bladder and the rectum to the vagina, which results n uncontrolled leakage of urine and faeces through the vagina. Added to this is Dysparunia, which is the experience of severe pains during sexual intercourse. Infertility is usually nightmare in area where betrothal means procreation. Some of these patients in extreme cases suffer from haematocolpos in which menstrual fluid is stopped and stored in the angina and haematometria where menstrual flow are restricted in the uterus and are never expressed.
Notwithstanding all the above stated conditions, some of these patients do get pregnant and the ultimate challenge is encountered during labour. This could lead to very bad vaginal lacerations during the second stage of labour or rather optionally Caesarian Section, like we had in our index case. The Diagnosis of female genital mutilation is not usually directed at confirming the existence of the condition but rather to manage the complications of the procedure or if possible to circumvent it with minimal interference of the already distorted vaginal anatomy. In some cases, based on mutual consent, there may be the necessity of bringing back the patient after confinement for reconstructive surgery or vaginoplasty. What is done would depend on how bad and dysfunctional the vagina is and what is left of normal tissue around it. As a rule, if there is no sexual and urination difficulties, the caregiver is better off looking the other way.
Female Genital Mutilation or Circumcision has no health benefit and should not be advocated for or practiced. It should be discouraged and condemned in its entirety. Deaths have been reported as a result of uncontrolled bleeding after the exercise and this is usually a traumatic experience to a young mother if a neonate is the victim. In this guise a lot of education and advocacy is needed to dissuade people from all religious and cultural background to desist from this treacherous practice. It is a variant of human right abuse.