Nawal M. Nour, MD, MPH


Chair of the Department of Obstetrics and Gynecology, Chief Diversity & Inclusion Officer for Faculty, Trainees and Students, Director of the African Women’s Health Center, Director of Ambulatory Obstetrics, Director of the Global Obstetrics & Gynecology Fellowship Training Program, Brigham and Women’s Hospital; Associate Professor of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA









Female Circumcision/Female Genital Mutilation: Clinical Management of Circumcised Women


The racial and ethnic composition of the United States has changed significantly during the past two decades.  Displaced by war, famine, political unrest and economic necessity, people from all over the world have immigrated in unprecedented numbers, bringing with them their distinctive cultural legacies.  One culturally determined practice that has gained international attention in recent years is female circumcision/female genital mutilation (FC/FGM).  Referring to any one of several traditional practices that involves the cutting of a female’s external genitalia; female circumcision is estimated to have affected over 130 million women and girls worldwide. Because of recent immigration patterns, women’s health care providers in the United States will increasingly encounter patients who have undergone female circumcision.

In 1990, the U.S. Department of Health and Human Services (DHHS) estimated that nearly 168,000 women and girls in the United States had either undergone or were at risk for FC/FGM and this figure is increasing.  In 1997, Congress directed the Secretary of the Department of Health and Human Services: 1) to identify communities in the U.S that practice FC/FGM; 2) to develop outreach and educational programs targeting these communities; and 3) to educate health care professionals and students about FC/FGM and the medical complications arising from it. It also became a U.S. federal crime to perform any medically unnecessary surgery on the genitalia of a girl younger than 18 years of age.  However, legislation outlawing FC/FGM is not sufficient in solving the public health issue associated with FC/FGM.  It is unlikely that medical professionals would be consulted by immigrants to perform FC/FGM on their daughters.  The practice would only come to the attention of authorities in cases of emergency and at that point it would be too late. Clearly, education directed toward at-risk populations is necessary.  But just as critical is educating social, public and medical service providers to administer culturally competent care.

The American College of Obstetrics and Gynecology has taken up the initiative to educate health providers by creating a slide-lecture kit for medical students, residents and obstetricians-gynecologists.   As its primary author, I solicited input from the community to develop a slide-lecture kit that would not only delineate the numerous medical consequences of this practice but also stress the need for cultural competency when providing care for these women.  The information contained in the slide-lecture kit is designed to fulfill four learning objectives. Practitioners should know: 1) the magnitude of the practice; 2) be able to recognize the different types of circumcision and their concomitant complications; 3) know the legal and ethical issues; and 4) understand the cultural importance of female circumcision.   Too many women carry the burden of educating providers about FC/FGM. It is important for providers to separate their attitudes toward the practice of FC/FGM from their approach to the patient who has undergone this procedure.  By combining the clinical guidelines along with cultural competency, the fundamental objective is to create better health outcomes for these women.

The slide-lecture kit is only effective if it is utilized frequently by health providers.  The next phase of this initiative is the evaluation process.   Leading this research, I will assess whether all medical schools and residency programs received the kits, how it is being utilized, whether the information is relevant and how it has impacted on care delivered to these patients.  The evaluation process is essential in order to determine whether this is a successful model in improving the health care administered to these women, as well as their health outcome.

Sponsoring Agency:

American College of Obstetrics and Gynecology