Female circumcision – a personal experience

It was a hot summer morning in KSA. I was still waiting for the next patient for consultation when my pretty Philippino nurse gracefully walked into my chamber and said I was wanted by the director of the hospital, Dr. Ahmed Laly. Amid howling hot wind as if coming from the hell in the corridor of the hospital in the desert city of Ryadh, Dr. Ahmed asked me in a low deep voice –
: Can you do circumcision?

Dr. Ahmed, an Egyptian dentist was about 6 feet tall with light skin having white golden hair and beard. His shoulders were unusually broad. He was looking at my eyes and waiting for the answer.

: Me!
I was really surprised. A general surgeon myself, I really felt insulted at his silly question. I felt my facial muscle tightened for sometime and I did not answer. After a few moments I calm down. It was Kingdom of Saudi Arabia and anything could be expected. I was working as a Consultant Surgeon of the Faisal National Hospital and Taiba Al Taiba Hospital of Ryadh.

: Yes, I can do circumcision.
The director was happy and took me to the place where a Saudi national clad in his traditional dress was standing with a new born in his hand.

A new born to circumcise who phallus is still so tiny that it is difficult to hold! However it is ok. Though not in Bangladesh, but I know the Arab people circumcise their babies just after birth. I have seen lot of these things while working in Libya. Then I gave a close look.

Oh my God! This was a baby girl! Instantaneously I refused. I could not say it is ghastly bad practice but I said, “I do not know how to circumcise a girl as this is not practiced in our country – Bangladesh. Dr. Ahmed Laly was very disappointed.

Introduction:
Female circumcision i.e. FGM (Female Genital Mutilation) or F.G.C (Female Genital Cutting) is a long standing cultural practice of cutting away parts of external female genitalia and most commonly practiced in girls between ages 4-8 years though it may be done at any age from infancy to adolescence.

Definition:
FGM is define by WHO as all procedures that involves partial or total removal of external female genitalia or other injury to the female genital organs for non-medical reasons.

Anatomical consideration:
The female external genital organs (Pudendum) or Vulva) include the mons pubis, the labia majora, labia minora, the clitoris, the vestibule of the vagina, the bulbs of the vestibule, the greater vestibular glands, and the vaginal orifice.

Mons containing subcutaneous fat lies in front of pubic symphysis and covered by pubic hair. Labia majora are 2 thick folds of skin whose outer surface is covered with hair and inner surface is studded with sebaceous glands and enclose pudendal cleft. Labia minora are also 2 folds of skin but they are thin. Anteriorly each labium minus splits into 2 layers.

The upper layer with that of opposite side form prepuce of clitoris and lower layer of 2 sides form frenulum of clitoris. The clitoris is homologous with penis, made of erectile tissue and its glands is extremely sensitive. Vestibule is the space between 2 labia minora containing orifices of urethra, vagina, ducts of greater and lesser vestibular glands.

The vulva and the adjacent areas of thighs are mainly supplied by nerves of lumbar and sacral plexus. These are iliohypogastric (T12, L1), ilioinguinal (L1), genitofemoral (L1, L2) and the posterior femoral cutaneous nerve (S1, 2, 3).

The pudendal nerve (S2, 3, 4) is the nerve of the perineum, supplies lower 1 inch of vagina and external genitalia. The perineal nerve is the larger terminal branch of pudendal and terminates by dividing into medial and lateral labial nerves.

Mons pubis and labia majora are provided with Meissner corpuscles, Merkel’s tactile discs and peritrichial endings which are mainly touch organs. Pacini’s corpuscles concerned with sexual stimuli are found in labia minora and clitoris.

Statistics:
Ethiopia has the highest level of FGM. A demographic survey conducted in 2005 states 75% of women has been subjected to it in Western, Eastern, North Eastern Africa and in parts of middle East. It is even done in Europe, North America, Australia and Canada in some immigrant communities. 100-140 million women and girls around the world are subjected to it of which 92 million in Africa. Another study found it is 98% in Somalia, 83% in Sudan, 5% in Zaire.

It is also done in Iraq, Jordan, Syria, Yemen, Senegal, Mauritania, Saudi Arabia, Egypt, Kurdistan, Gambia, Djibuti, Kenya, Tanzania, Mozambique etc. It is estimated that 100,000 women in Britain have undergone the procedure.

 In 2010 about 2000 British school girls underwent circumcision during summer holiday (source internet). Even sometimes sporadic cases are reported from India and Pakistan. Small Muslim sub sect Dawoodi Bohra in India continues to believe removal of clitoris is the will of God.n   (Reprint)