Female circumcision and mutilation have negative impacts on public and individual health, however the practice continues, rooted in culture and history in nearly thirty African and Middle Eastern countries (Cook, 2008). While it is not known when or how the practice began, there is some evidence from mummified bodies that female circumcision was practiced in Ancient Egypt about 200 BC (Dirie & Lindmark 1992). Also, prior to the introduction of Islam it was common in Egyptian, Roman and Arabian communities There is considerable controversy about the practice, particularly with regard to women’s rights and equality, but such advocacy is external to the communities where female circumcision is practiced leading to claims of disrespect for culture. This creates an awkward dynamic with those providing health care caught between cultural tenets.
Today female circumcision affects an estimated 125 million females in the world (Berg et. al. 2014). As the circumcision is carried out informally by non-medical practitioners, there is no clear way of tracking the practice (Drolet 2015). The World Health Organization describes three categories of female circumcision. These are Type I where the clitoris is remove, type II which involves excision, type III is pharaonic circumcision, also called infibulation, and type IV includes all not covered under other types of female circumcision (Berg et. al. 2014). Type III is considered the most drastic of these, however 87% of Somali women undergo the ritual at about age 8 (Van der Kwaak 1992).

The use of the term circumcision is as a parallel to male circumcision, however while male circumcision results in increased health outcomes, female circumcision does not (Drolet 2015). Complications that occur soon after the procedure include excessive bleeding, genital tissue swelling and urine retention (Berg et. al. 2014). There are also significant long term negative outcomes for women who have undergone circumcision and mutilation including urinary tract infections, bacterial vaginosis, dyspareunia, prolonged labor, caesarean section and difficult delivery (Ibid.). Increased maternal morbidity and fetal loss is often the result (De Silva 1989).

In type III the entire clitoris is removed along with the minor labia and parts of the major labia (Dirie & Lindmark 1992). What is left of the major labia is stitched together, and the only opening that remains is a small one in the lower vulva in order to allow urine and menstrual blood out of the body, but at a slow dribble (Ibid.). The health and sexuality of the female who has undergone this procedure is permanently altered, and will remain closed until naturally defibulated by regular sex. This only expands the opening, and of course the clitoris does not grow back.

For health care professionals there are two areas that are cause for concern, that being the danger of a request to assist in female circumcision and the difficulty of delivering the care and treatment to females who have already undergone the practice (Toubia 1994).

There are many psychological and cultural factors involved in female circumcision. In communities where the practice is widespread, it increases the perceived value of the female. Female circumcision is valued by parents as it is seen as ensuring chastity and continuing community identity, although researchers also found they were concerned about potential negative outcomes (Abdelshahid & Campbell 2015). A study of Somalian parents who had moved to the West reported that the support for female circumcision was largely rooted in the belief that it was a requirement of Islam (Gele et. al. 2012).

Many in the West have a great deal of difficulty reconciling the practice of female genital mutilation to the idea of cultural relativism, however when persons from practicing communities move to Western nations many abandon it. A study in Oslo, Norway, indicated that fully 70% of Somalis there supported an end to female circumcision (Gele et. al. 2012). Of the 30% who continued to support the practice, most had been living in Norway for less than 4 years (Ibid.). It would appear that when families from communities are outside of the context where female circumcision is practiced, there is a rapid decline in its occurrence.

For nurses and health care professionals, even in developed nations, knowledge about female circumcision and the later risks in life are important in order to provide appropriate care and to mitigate known risks. This can be especially important in childbirth. The health care professional must not focus on the political or cultural issues, but rather the best possible outcomes. This may also occur in the context of families seeking more information about female circumcision. This can provide an important opportunity for psychoeducation which reduces the number of girls who are circumcised. It can be a very difficult matter to bring up, and one that affected women may be hesitant to talk about in the health care setting. Calder, Brown, and Rae (1993) provide some guidance with regard to culturally sensitivity for health care professionals who are providing care for such patients, including awareness of the practice, identification of possible complications in various situations and acceptable interventions that are considered culturally appropriate or inappropriate.

Female circumcision can be an uncomfortable topic, but ensuring good patient outcomes requires not only understanding the practice and context, but also technical aspects of care and cultural factors that lead to acceptance of the treatment. Given the large number of African and Middle Eastern immigrants to the Western world, it is important that nurses and other health care professional are aware and ready to provide appropriate care.

References
• Abdelshahid, A., & Campbell, C. (2015). ‘Should I Circumcise My Daughter?’Exploring Diversity and Ambivalence in Egyptian Parents’ Social Representations of Female Circumcision. Journal of Community & Applied Social Psychology, 25(1), 49-65.
• Berg, R. C., Underland, V., Odgaard-Jensen, J., Fretheim, A., & Vist, G. E. (2014). Effects of female genital cutting on physical health outcomes: a systematic review and meta-analysis. BMJ open, 4(11).
• Calder, B. L., Brown, Y. M., & Rae, D. I. (1993). Female circumcision/genital mutilation: culturally sensitive care. Health Care for Women International, 14(3), 227-238.
• Cook, R. J. (2008). Ethical concerns in female genital cutting. African Journal of Reproductive Health, 12, 7–16.
• De Silva, S. (1989). Obstetric sequelae of female circumcision. European Journal of Obstetrics & Gynecology and Reproductive Biology, 32(3), 233-240.
• Dirie, M. A., & Lindmark, G. (1992). The risk of medical complications after female circumcision. East African medical journal, 69(9), 479-482.
• Drolet, J. (2015). Integrating culture gender and human rights: Supporting community-level strategies to eradicate female genital mutilation/cutting (FGM/C) in Africa. Reflections: Narratives of Professional Helping, 17(1), 54-64.
• Gele, A. A., Johansen, E. B., & Sundby, J. (2012). When female circumcision comes to the West: Attitudes toward the practice among Somali Immigrants in Oslo. BMC public health, 12(1), 697.
• Toubia, N. (1994). Female circumcision as a public health issue. New England Journal of Medicine, 331(11), 712-716.
• Van Der Kwaak, A. (1992). Female circumcision and gender identity: A questionable alliance?. Social Science & Medicine, 35(6), 777-787.