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Reliability of self reported form of female genital mutilation and WHO classification: cross sectional study

BMJ 2006; 333 doi: (Published 13 July 2006) Cite this as: BMJ 2006;333:124
  1. Susan Elmusharaf, medical doctor (Sozan.Elmusharaf{at},
  2. Nagla Elhadi, medical doctor2,
  3. Lars Almroth, medical doctor1
  1. 1 Division of International Health, Karolinska Institutet, SE 171 77 Stockholm, Sweden,
  2. 2 Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Khartoum, 102 Kartoum, Sudan
  1. Correspondence to: S Elmusharaf
  • Accepted 24 March 2006


Objective To assess the reliability of self reported form of female genital mutilation (FGM) and to compare the extent of cutting verified by clinical examination with the corresponding World Health Organization classification.

Design Cross sectional study.

Settings One paediatric hospital and one gynaecological outpatient clinic in Khartoum, Sudan, 2003-4.

Participants 255 girls aged 4-9 and 282 women aged 17-35.

Main outcome measures The women's reports of FGMthe actual anatomical extent of the mutilation, and the corresponding types according to the WHO classification.

Results All girls and women reported to have undergone FGM had this verified by genital inspection. None of those who said they had not undergone FGM were found to have it. Many said to have undergone “sunna circumcision” (excision of prepuce and part or all of clitoris, equivalent to WHO type I) had a form of FGM extending beyond the clitoris (10/23 (43%) girls and 20/35 (57%) women). Of those who said they had undergone this form, nine girls (39%) and 19 women (54%) actually had WHO type III (infibulation and excision of part or all of external genitalia). The anatomical extent of forms classified as WHO type III varies widely. In 12/32 girls (38%) and 27/245 women (11%) classified as having WHO type III, the labia majora were not involved. Thus there is a substantial overlap, in an anatomical sense, between WHO types II and III.

Conclusion The reliability of reported form of FGM is low. There is considerable under-reporting of the extent. The WHO classification fails to relate the defined forms to the severity of the operation. It is important to be aware of these aspects in the conduct and interpretation of epidemiological and clinical studies. WHO should revise its classification.


  • Funding Swedish International Development Agency, Sida/SAREC, the Regional Research Council of Northeast Skåne, Sweden, and the Department of Paediatrics, Centralsjukhuset, Kristianstad, Sweden.

  • Competing interests None declared.

  • Ethical approval The University of Khartoum, the Children's Emergency Hospital, Khartoum, Sudan, and the Karolinska Institute, Sweden, approved the study.

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