Female genital mutilation or cutting — formative SAQs

SAQ 1 — Recognition, classification, and safeguarding (10 marks)

A six-year-old girl of Somali background is referred to your clinic with a three-month history of recurrent urinary tract infections. Her mother, who has recently migrated to Australia, speaks limited English and has brought the girl's maternal grandmother, who is visiting from Mogadishu. On genital examination you find the labia majora fused with a pinpoint opening, consistent with Type III infibulation. [4]

Questions

1. Describe the WHO Type I–IV classification of FGM and state which type this child has. Explain why FGM performed on a minor is always child abuse. (4 marks) [4]
2. Outline the immediate safeguarding and reporting steps you must take, including who you must screen and who you must not use as interpreter. (3 marks) [4]
3. Describe the physical and psychological complications this child is at risk of, and the investigations and referrals you would arrange. (3 marks) [1] [2]

Model answer

Classification and child-abuse status (4). Type I (clitoridectomy) is partial or total removal of the clitoris and or prepuce. Type II (excision) is partial or total removal of the clitoris and labia minora, with or without the labia majora. Type III (infibulation) is narrowing of the vaginal opening by cutting and appositioning the labia minora or majora, with or without excision of the clitoris — the most severe form. Type IV covers all other harmful procedures including pricking, piercing, incising, scraping, and cauterising. This child has Type III. FGM performed on a minor is always child abuse regardless of who performs it, the cultural motivation, or whether it is medicalised, because it causes immediate and lifelong harm with no health benefit and violates the child's right to bodily integrity. [4]

Safeguarding and reporting (3). Make a mandatory child-protection report immediately, because FGM is a criminal offence in all Australian states and territories and mandatory reporting applies to medical practitioners. Agree a multi-agency safety plan so the child is not returned to an environment where further harm is possible. Screen every sibling — particularly any younger sisters — because cutting is familial and recurrent. Use a professional interpreter, never a family member, because the safeguarding implications make family-member interpretation unsafe. Do not let the child leave the clinic without a safety plan in place. [4]

Complications, investigations, and referrals (3). Physical complications include recurrent UTI from urinary stasis, dysmenorrhoea, haematocolpos in adolescence, dyspareunia, and obstetric complications including prolonged labour, postpartum haemorrhage, and obstetric fistula. Psychological complications include PTSD, depression, and anxiety. Arrange a urinalysis and urine culture, a pelvic ultrasound to assess for haematocolpos or cysts, and a mental-health screen. Refer to a specialist FGM or gynaecology service for deinfibulation planning, and to psychology or psychiatry for trauma-focused therapy. [1] [2]

SAQ 2 — Acute presentation and the deinfibulation pathway (10 marks)

A fourteen-year-old girl presents to the emergency department with severe lower abdominal pain and an inability to pass urine for twelve hours. She is distressed and in significant pain. Her family migrated from Sudan two years ago. Examination reveals a Type III infibulation with an inflamed, narrowed opening. She is also found to have early haematocolpos on ultrasound. [1] [3]

Questions

1. Describe your immediate resuscitation and acute management, naming the emergency and the intervention required. (4 marks) [1]
2. Outline the deinfibulation pathway you would plan for this girl, including the timing, the counselling, and the multidisciplinary team involved. (4 marks) [3]
3. State your safeguarding and follow-up obligations after this presentation. (2 marks) [4]

Model answer

Acute management (4). This girl has acute urinary retention secondary to the narrowed introitus of a Type III infibulation, complicated by early haematocolpos from retained menstrual blood. Urinary retention in this setting is a medical emergency — the narrowed opening can completely block urinary flow, leading to bladder distension and potential renal damage. The immediate intervention is to relieve the obstruction, which may require urethral catheterisation if possible or an incision of the infibulation scar under adequate analgesia or anaesthesia. Give adequate analgesia including opiates, assess for sepsis or local infection, and arrange urgent urogynaecology or surgical review. Do not defer the intervention for non-urgent workup; the obstruction must be relieved first. [1]

Deinfibulation pathway (4). Deinfibulation is the definitive surgical procedure for Type III, opening the scar to restore a functional vaginal opening. Plan it electively once the acute presentation is resolved, performed by a gynaecologist or FGM specialist surgeon with experience in the procedure. The counselling must address the girl's fears, her understanding of what the procedure involves, the expected outcome for urinary, menstrual, and sexual function, and her preferences and consent as a mature minor. The multidisciplinary team should include the surgeon, a psychologist for trauma-focused support, and a specialist nurse or community health worker with FGM expertise. In the longer term, if she chooses, reconstructive surgery can be offered in a multidisciplinary model combining surgery, psychology, physiotherapy, and sexual counselling. [3]

Safeguarding and follow-up (2). Make a mandatory child-protection report, screen every sibling for cutting or risk, and agree a multi-agency safety plan. Arrange follow-up with the FGM or gynaecology service for deinfibulation, with psychology for ongoing trauma-focused therapy, and with the general paediatrician for the longitudinal relationship that supports the girl and her family over time. [4]