Caring for Women with Circumcision: A Technical Manual for Health Care ProvidersBMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7247.1481 (Published 27 May 2000) Cite this as: BMJ 2000;320:1481
RAINBO, $17.95, pp 94
ISBN 1 893136 01 9
A 19 year old Somali refugee woman presented in labour. She spoke no English. Examination of her vulval area showed a long scar in place of her external genitals, with only a tiny opening. The senior resident called to advise thought that he remembered hearing about ritual cutting, and managed to track down a colleague who had worked in Somalia. Over the telephone, she explained that the woman was infibulated and needed defibulation in the second stage of labour. Instructions were faxed over from another state, and the baby was delivered successfully.
This case history from Toubia's book illustrates some of the difficulties encountered both by affected women and by doctors. Toubia writes as an African woman and a physician, and her manual provides concise and accessible coverage of the cultural, physical, and emotional complexities of female circumcision. This is also, more controversially, termed female genital mutilation; Toubia considers that both terms have their place, with “female circumcision” being more useful in the clinical setting.
Female circumcision affects about 100 million women and girls worldwide. Their risk of dying in childbirth is doubled and of having stillborn babies trebled, and other physical, sexual, and relationship problems are common. Although female circumcision is now illegal in many countries, the practice continues in much of sub-Saharan Africa, among various religious groups, as a rite of passage into womanhood or a way of preserving virginity until marriage.
The extent of physical damage ranges from a clitoral nick to complete infibulation, when the external genitalia are removed and the vaginal opening narrowed by stitching. The different types are clearly described in the book, supplemented by a laminated sheet of illustrations and diagrammatic instructions for defibulation. Although the classification of circumcision is precise, Toubia comments that the performance of the surgery frequently is not, as it often involves a traditional circumciser, poor lighting, and an unanaesthetised child who is screaming and wriggling.
The practicality of this book extends not only to the medical, gynaecological, and obstetric needs of those circumcised but also to the section on communication. This is masterly, with cogent advice on topics such as asking about past circumcision, giving information (use pictures for women with low literacy), and employing interpreters (avoid using patients' children). The section on the law has been written for the US market but also summarises the position elsewhere.
This is a valuable reference for a topic poorly covered in mainstream textbooks and is a compelling read for clinicians who wish to develop the skills to manage affected women capably and sensitively.
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