Female genital mutilation and gender-based violence

• Female genital mutilation (FGM) is the partial or total removal of, or other injury to, the external female genitalia for non-medical reasons. It has no health benefit and is a human-rights violation and a form of child abuse when performed on a girl.
• More than 230 million girls and women alive today have had FGM, mostly in parts of Africa, the Middle East and Asia; over four million girls are estimated to be at risk each year.^[1][6]
• Harm is not only immediate: FGM causes chronic pain, urinary and sexual problems, obstetric complications and psychological harm, and remains a lifelong clinical issue for the women living with it.
• Women with FGM may need deinfibulation (opening an infibulated scar) for symptoms, sexual health or childbirth; reinfibulation is not recommended.
• Both FGM and intimate partner violence are part of gender-based violence: the health system is often the first place a woman can be heard, so recognition, safe enquiry and woman-centred response are clinical skills, not optional extras.

By the end of this topic you should be able to:

1. Define FGM and classify it into the four WHO types and their subtypes.
2. Explain the immediate and long-term complications of FGM across the life course and why more extensive forms carry greater risk.
3. Plan care for a woman with FGM: deinfibulation when and how, care in pregnancy and childbirth, sexual health and psychological support.
4. Explain the legal status of FGM, the duty to safeguard girls under 18, and how mandatory reporting differs from care for adult women.
5. Recognise intimate partner violence (IPV) from its presentations and red flags, and explain why routine universal screening is not recommended but clinical enquiry is.
6. Describe the LIVES first-line support response, safety planning, documentation and referral, and the rules on mandatory reporting of IPV. ^[11]

The words matter. "Female circumcision" is misleading, because male circumcision removes foreskin only, while FGM removes or damages sensitive tissue and, in its most extensive form, closes the vaginal opening. "Female genital cutting" (FGC) and "FGM/C" are also used, but "mutilation" is retained by the United Nations system and by clinical guidelines because the procedure is harmful, is performed on non-consenting children, and is a violation of human rights.^[7]

FGM is nearly always performed on minors, most often between infancy and adolescence.^[1] It predates the religions associated with it: no religious scripture prescribes it, and religious authorities hold varying positions, some of them publicly against it.^[1]

The World Health Organization (WHO) classified FGM into four types in 1997, later subdivided to capture detail.^[2] All four occur in practice; Type 3 is the only one that may later require deinfibulation.

This is now a worldwide clinical issue, not a specialty curiosity.

• More than 230 million girls and women alive today have undergone FGM, in 30 countries in Africa, the Middle East and Asia, with the largest burden in Africa (over 144 million), followed by Asia (over 80 million) and the Middle East (over 6 million).^[1][6]
• Over four million girls are estimated to be at risk of FGM every year.^[1][5]
• Health workers themselves are involved: as of 2020 an estimated 52 million girls and women had been subjected to FGM at the hands of health workers, roughly one in four cases.^[5]
• The Sustainable Development Goals set a target to end FGM by 2030. UNICEF estimates that progress would need to be 27 times faster than the rate of the last decade to meet it.^[6]
• Treatment of the health complications of FGM costs health systems about US$ 1.4 billion per year, a figure expected to rise if the practice continues.^[1]

There has been real progress: since 1990 the likelihood of a girl undergoing FGM has fallen about threefold, and some countries have cut prevalence in 15 to 19-year-olds by a quarter to a half over 30 years.^[5] That progress must not be oversold to a patient, though; in 2026 over four million girls were still described as at risk by UN leaders, calling for sustained commitment and investment.^[1]

Understanding why helps with counselling and with not judging the woman in front of you. The reasons are mixed and sociocultural: conforming to a social norm; preparing a girl for adulthood and marriage, including beliefs about controlling sexuality and promoting premarital virginity and marital fidelity; and the mistaken belief that the practice has religious support.^[1]

Medicalization is a particular problem for us as health workers. It persists because of the belief that performing FGM in a clinic is safer than in the community, that medicalization is a first step towards abandonment, because providers are themselves members of practicing communities and subject to the same norms, and because of financial incentive.^[1] WHO is explicit that medicalization does not make FGM acceptable: it remains harmful from a medical and ethical standpoint, and health workers must be agents for change, not perpetrators.^[1][5]

Harm rises with the extent of the procedure: all forms increase risk, but more extensive forms carry greater risk.^[1][3]

Given the scale of long-term harm, many women need repeated, sensitive encounters across gynaecology, obstetrics, urology, sexual health and mental health services rather than one referral.

The sexual consequences deserve more than a line in a table. Removal of or damage to highly sensitive tissue, especially the clitoris, can reduce sexual sensitivity, desire and pleasure, cause pain during sex and penetration, and reduce lubrication; scar formation, pain and traumatic memories can also drive sexual dysfunction.^[3]

FGM is associated with pelvic and back pain, infections and discharge, which feed into recurrent consultations and, when infertility is suspected, investigations that should be conducted with awareness of the possible anatomical and psychosocial context.^[3]

Mental health problems are among the long-term consequences: depression, anxiety, post-traumatic stress disorder and low self-esteem.^[1][3] Ask about them routinely when a woman with FGM is seen, because disclosure of distress often waits until trust has been established.

Deinfibulation is the surgical opening of the sealed vaginal opening created by Type 3 (infibulated) FGM. It cuts through the infibulated scar tissue over the vaginal opening, restoring the vaginal introitus.^[2][8][9]

It is often called a "reversal," but that name is misleading: it does not replace tissue that was removed and cannot undo the underlying damage. What it can do is relieve many of the problems FGM causes.^[8][9]

Indications include difficulty with urination or with menstrual outflow, inability or pain with penetrative intercourse, and any pregnancy in which the sealed opening would obstruct labour or delivery.^[2][9] It should also be offered simply because the woman wants it. It should ideally be carried out before conception where possible, and otherwise during pregnancy or labour; in routine pregnancy care it is ideally done within the first two trimesters, by 20 weeks.^[8][9] In practice it can be performed antenatally, in the first stage of labour or at the time of delivery, usually under local anaesthetic in a delivery suite.^[8]

Deinfibulation should be preceded by counselling and fully informed consent, including honest discussion of what the procedure can and cannot achieve and what recovery involves.^[4] The WHO 2025 guideline makes counselling and informed consent before deinfibulation a best practice statement, and recommends tackling deinfibulation together with the timing of the procedure among its recommendations.^[4]

Reinfibulation is the re-closure or narrowing of the vaginal opening after deinfibulation, sometimes requested after childbirth. WHO recommends against it because it increases health risks across the life course.^[2] In the United Kingdom it is illegal to reinfibulate after childbirth.^[8] Where women ask about it, this is a moment for careful, non-judgemental counselling about health, safety and the law in that jurisdiction.

After deinfibulation document the woman's symptoms before and after, complications such as bleeding and infection, and, where pregnancy is involved, delivery outcomes. Offer pain relief, wound support and follow-up. Ensure that sexual health review, mental-health referral and safeguarding are offered alongside the procedure rather than left for another visit.

FGM is a violation of the human rights of girls and women: it breaches the rights to health, physical integrity, freedom from torture or cruel, inhuman and degrading treatment, and, in fatal cases, the right to life.^[1][6][7] The RCOG Green-top guideline describes FGM as a form of child abuse, breaching the United Nations Convention on the Rights of the Child, and as a severe form of violence against women and girls.^[7]

The United Nations (through UNICEF data and the interagency statement on eliminating female genital mutilation, alongside WHO) frames FGM alongside child marriage and other harmful practices in the Sustainable Development Goal target to end harmful practices by 2030.^[6][1] Legal progress matters clinically: in most high-income countries FGM is a criminal offence, but criminalization can dissuade women from seeking care, so the clinical role is care first, reporting according to the law, and ongoing trust.

FGM is also strongly associated with intimate partner violence.^[7] In many settings the same gendered power dynamics produce both, so a woman being seen for FGM-related care should be asked routinely (and privately) about violence in her relationships; the inverse holds for women presenting with injuries or controlling partners.

In the United Kingdom, FGM is illegal under the Female Genital Mutilation Act 2003 in England, Wales and Northern Ireland, and under the Prohibition of Female Genital Mutilation (Scotland) Act 2005 in Scotland.^[7][8] RCOG makes all health professionals responsible for awareness of these Acts.^[7]

In the United Kingdom, a healthcare professional who encounters FGM in a girl under 18 in the course of work has a mandatory duty to report it to the police. That duty came into force on 31 October 2015.^[10] Under-18 cases should also be referred to the local safeguarding team, and the RCOG patient information states that professionals are obliged under law to report under-18 FGM to the local safeguarding team and the police, who should handle the matter sensitively.^[8]

Adult women with FGM are not subject to mandatory police reporting in the same way; care should be offered without coercion and with confidentiality preserved. Where there may be risk to children in the family or household (daughters, younger sisters, granddaughters), follow local child safeguarding and protection pathways. NHS guidance stresses that professionals have responsibilities to safeguard and protect women and girls from FGM, with specific duties where girls under 18 are involved.^[9] Regional law differs, so be clear about the law and pathways where you practice.

Intimate partner violence (IPV) is abuse by a current or former intimate partner. It includes physical violence, sexual violence, psychological or emotional abuse, and coercive and controlling behaviour. Gender-based violence is the broader term that also includes non-partner sexual violence, female genital mutilation, forced marriage, honour-based violence and exploitation. IPV is the most common form of violence against women.

The WHO 2013 clinical and policy guidelines were built on systematic reviews and remain the central health-sector reference for a clinical response.^[11] WHO frames violence against women as a major public health and human rights issue, with IPV and sexual violence among its most pervasive forms.^[11]

About one in three women worldwide have experienced physical and/or sexual violence in their lifetime, most often by an intimate partner.^[11] Women who have experienced violence seek health care more often than women who have not, even when they do not disclose violence as the reason, and they identify health-care providers as the professionals they would most trust with disclosure.^[11] This is why the clinical setting matters so much.

The list is deliberately wide, because IPV rarely announces itself:

• Repeated injuries, especially in the head, neck, trunk or genitals, or injuries whose explanation does not fit.
• Chronic pain presentations such as headache, pelvic pain, back pain and abdominal pain without a clear physical cause.
• Mental health and substance difficulties: anxiety, depression, post-traumatic stress, self-harm, suicidal thoughts.
• Sexual and reproductive health clues: unwanted pregnancy, repeated sexually transmitted infections, dyspareunia, late booking in pregnancy, miscarriage or stillbirth.
• Somatic and behavioural clues: poor sleep, eating difficulties, panic, social withdrawal, missed appointments, or a patient who minimizes or dismisses her own symptoms.
• Pregnancy-related clues in particular: controlling partner accompanying and answering for the woman, restricted access to money or transport, delayed antenatal care.
• A partner who is excessively attentive, speaks for her, or refuses to leave the room, or a consultation that only happens when a third party is absent.

None of these proves IPV; all of them justify a gentle, private enquiry.

WHO does not recommend routine universal screening of all women for IPV in the absence of signs or symptoms.^[11] Instead, clinical enquiry is recommended when violence is suspected or when risk indicators are present.^[11] The reasons are practical: universal screening without training, time and referral pathways can be ineffective or harmful, while sensitive enquiry with follow-up support saves lives. The experience base is that the question is a clinical intervention in itself when asked well.

A private, single-clinician setting is essential. Ask directly but gently, in the woman's own language where possible, and always without her partner or a family member present (interpreters should be independent, not a relative). Useful open questions include:

• "Do you feel safe at home?"
• "Has anyone close to you ever hurt you or frightened you?"
• "Does anyone currently control your money, your decisions or who you see?"
• "Have these symptoms ever occurred after an argument or after being hurt?"

Document whether a partner or relative was present and whether an independent interpreter was used.

• Listen. Give time, sit, do not interrupt. Listen without judgement. Non-verbal behaviour matters as much as words.
• Inquire. Ask about needs and concerns, what would help, and what she wants now. Do not press for a full account of events.
• Validate. Believe her. State clearly that violence is common, that it is not her fault, and that what happened to her is wrong.
• Enhance safety. Assess immediate danger now: is the perpetrator at the clinic, waiting outside, or expected at home? Is there a weapon? Are children at risk? Build a safety plan with her: packed bag, important documents, phone numbers, agreed code word, safe place to go, emergency number.
• Support. Offer practical help: documenting injuries, referral to shelter and advocacy services, legal advice, mental health care. Give written information about services (this is a specific WHO recommendation for IPV care).^[11]

Do not do the following: do not advise a woman what to do (she is the expert on her own safety); do not contact her partner or family member without her consent and, where a child is at risk, without following safeguarding law; do not require her to make a police report before receiving care; and do not carry out forensic examination unless she wants it and has capacity to consent.

For a woman who discloses sexual violence, follow local sexual assault and forensic pathways with her consent. WHO guidance covers comprehensive care: first-line support, a careful history, management of injuries, emergency contraception, sexually transmitted infection and HIV prophylaxis where indicated, hepatitis B vaccination as appropriate, pregnancy assessment and management, and psychological support.^[11] Emergency contraception is most effective when offered promptly. Document findings, with consent, in a form that may support future legal proceedings, but the primary purpose of the record is her care.

IPV produces depression, anxiety, post-traumatic stress and suicidal ideation, which may outlast the relationship. Provide psychological emergency care at the visit, offer referral to trauma-focused cognitive-behavioural therapy or other local services, and ask about self-harm and safety. Treatment of physical injuries should not eclipse this.

Record injuries descriptively and, with consent, with photographs or body maps. Record the woman's own words in quotes. Document risk assessment and safety planning. Keep notes secure, because information can put her at risk if accessed by the perpetrator.

Contrary to common assumption, WHO does not recommend mandatory reporting of IPV to the police by health-care providers. Mandatory reporting is not recommended; instead the provider should offer to report the incident if the woman chooses, supporting an informed, autonomous decision.^[11] This applies to adult women without dependent children at immediate risk.

Exceptions apply. Where a child is at risk, or a vulnerable adult is at risk, or there is imminent serious danger to life, follow local child-protection and adult-safeguarding law, which may require escalation beyond the woman's wishes. Know your jurisdiction: some regions have mandatory reporting laws for specific injuries. Always explain to the woman what will and will not be shared before it happens.

Pregnancy is often the moment FGM is first addressed clinically. Good care rests on simple steps:

• Ask about FGM at the booking visit, before anyone else is present where possible; use a professional interpreter rather than a family member.^[8][9]
• Examine and record the type of FGM and its impact, then plan care accordingly.
• Offer cervical screening and sexual health review where appropriate, alongside obstetric planning.
• Offer deinfibulation antenatally, ideally within the first two trimesters, or plan for intrapartum deinfibulation if needed.^[8][9] If no deinfibulation is needed, support normal labour.
• Make clear that reinfibulation will not be performed under any circumstances, and discuss this before labour, not during it.^[8]
• Offer screening for blood-borne viruses as for any woman in pregnancy where indicated, including hepatitis C where practice supports it.
• Document the care plan and share it across the team.
• In labour, allow time and an appropriate position, avoid unnecessary episiotomy, and repair any trauma with standard technique; perineal and genital trauma guidance still applies.^[7]
• Offer follow-up and counselling after birth, including psychological and sexual health support.

Where children or adolescents are involved, or when a woman has daughters:

• A girl at risk of FGM is a child-protection issue, not only a cultural one.
• Mandatory reporting to police (in the UK, for under-18s) and local safeguarding referral are triggered.^[10]
• Counselling of parents and family should be delivered by trained specialists and should be non-judgemental about culture while being clear about health, law and safeguarding.
• Record exactly what was said and decided; never undertake FGM or medicalized FGM.^[1][5]

• A trained provider with a speculum and a good light can often diagnose FGM and its type without advanced equipment; the clinical history then drives management.^[3][7]
• Deinfibulation can be performed under local anaesthetic in a delivery suite room and needs only basic instruments and resuscitation capacity; arrange referral where more complex surgery is needed.
• Specialist FGM services are concentrated in cities; plan referral pathways in advance, including for antenatal care.
• Where counselling services are scarce, the LIVES approach, clear written information, and a known safety plan can still protect women.
• Training health workers in prevention, care and counselling is one of the eight recommendations of the 2025 WHO guideline and should be requested for your workplace if it is not offered.^[4]

• FGM is defined as non-medical injury to the female genitalia and has no health benefit; it is a human-rights violation and child abuse when performed on girls.
• There are four WHO types: clitoridectomy, excision, infibulation and other procedures; more extensive forms carry greater risk.
• Over 230 million girls and women live with the consequences of FGM; over four million girls are at risk each year and 52 million were cut by health workers by 2020.
• Immediate complications include haemorrhage, infection and death; long-term complications include urinary, genital, menstrual, sexual, obstetric and psychological harm.
• Deinfibulation can relieve symptoms and facilitate birth, but does not restore removed tissue; reinfibulation is not recommended and is illegal in some countries such as the UK.
• Health workers must not perform FGM, including medicalized FGM; they should use professional codes of conduct to resist pressure.
• In the UK, FGM in under-18s is reportable to police and safeguarding teams (duty in force 31 October 2015); adult women are not subject to the same automatic reporting.
• Safeguarding children at risk is distinct from providing care to women already affected; both are required.
• IPV and FGM are both forms of gender-based violence and frequently co-occur; sensitively ask about both.
• WHO does not recommend universal screening for IPV but supports clinical enquiry when indicators exist, in a private setting with an independent interpreter.
• First-line support for disclosure follows LIVES: Listen, Inquire, Validate, Enhance safety, Support; always offer written information and a safety plan.
• IPV mandatory reporting to police by a health-care provider is not recommended by WHO; report only if the woman chooses, except where children or vulnerable adults are at risk or there is imminent danger.
• Clinical care after sexual violence includes appropriate forensic services, emergency contraception, STI and HIV prophylaxis and psychological support, with consent.
• FGM-related pregnancy care rests on antenatal deinfibulation when indicated, clear counselling that reinfibulation will not occur, and attention to sexual and mental health needs.

Obstetric emergencies and collapse; caesarean section and episiotomy; postpartum haemorrhage; perineal repair; sexual health; contraception; antenatal care; preeclampsia, HELLP and eclampsia; mental health in pregnancy; sepsis and infections in pregnancy; postpartum infection; sexual assault assessment and care; child abuse and neglect; menstrual disorders; dyspareunia; urinary tract infection; mental health and trauma; human rights, law and professional duty. Links to other MedGrasp topics are shown as plain text only.