In my presentation I present my personal experience about Female Genital Mutilation (FGM) gained during my work in Eritrea and Somalia. A precondition to solve (stop) FGM is the acceptance of different and contested customs in humankind practiced. Furthermore it is essential to understand for outsiders that no one is more right than the other. To stop FGM it is a precondition to remove stigmas and let all girls know they are beautiful and accepted, no matter what the appearance of their genitalia or their cultural background are otherwise sexual dysfunction and feelings of inferiority in circumcised women become a true self-fulfilling prophecy.

1. Practical Aspects about Female Genital
Mutilation
Dr Dirk Grothuesmann, MScHI, MDMa
http://dg-maternalhealth.de/

4. “To understand as outsiders why FGM is still practiced we must accept different
cultural perspectives on female circumcision with regard to pleasure, hygiene and
genital aesthetics and not insist that uncircumcised Western women opponents
have it right and circumcised African women proponents are wrong”
Dr med Hans-Georg Grothuesmann
Summer Set West, RSA, 2018
Dr Hans-Georg Grothuesmann a urologist
with work and life experience in Sub-Saharan
Africa of more than 50 years

5. Preface
“In humankind there are different and contested customs practiced and
it is essential to understand for outsiders that no one is more right than
the other. To stop FGM it is a precondition to remove stigmas and let all
girls know they are beautiful and accepted, no matter what the
appearance of their genitalia or their cultural background are otherwise
sexual dysfunction and feelings of inferiority in circumcised women
become a true self-fulfilling prophecy”
Dr Dirk Grothuesmann, 2020
https://dg-maternalhealth.de/

7. Code of Ethics for Medical Procedures
• Dedication to provide the best possible procedures based on
circumstances in place
• The medical person must realize the vulnerability and related root
causes of the population treated
• responsibilities for the stakeholders in the medical processes must be
assured
• No hubris, accept own and infrastructural limitations and select
patients and related treatment processes accordingly
• Collect/review data on treatment outcomes within the national legal
frame
Dr Grothuesmann,
own source 2019

8. Key Facts of FGM
• Female genital mutilation (FGM) involves the partial or total removal of external female
genitalia or other injury to the female genital organs for non-medical reasons
• The practice has no health benefits for girls and women
• FGM can cause severe bleeding and problems urinating, and later cysts, infections, as
well as complications in childbirth and increased risk of newborn deaths
• More than 200 million girls and women alive today have been cut in 30 countries in
Africa, the Middle East and Asia where FGM is concentrated
• FGM is mostly carried out on young girls between infancy and age 15
• FGM is a violation of the human rights of girls and women
• WHO is opposed to all forms of FGM, and is opposed to health care providers performing
FGM (medicalization of FGM)
• Treatment of health complications of FGM in 27 high prevalence countries costs 1.4
billion USD per year
WHO, 2020
https://www.who.int/news-room/fact-
sheets/detail/female-genital-mutilation

9. Female Perineum Anatomy
https://www.hopkinsmedicine.org/gynecology_obstetrics/pdfs/res
idency/anatomy/PelvicAnatomyForResident.pdf

10. Global Prevalence of FGM
https://en.wikipedia.org/wiki/Prevalence_of_female_genital_mutilation
accessed January 2021

11. Health consequences I
short term health issues
• Serve pain, shock, haemorrhage
• Infection (Tetanus, HIV),
• urinary retention,
• demage to adjacent tissue (urethra, anal sphincter, vagina)
• death can result for haemorrhage or infection
• Mental trauma
https://dg-maternalhealth.de/

12. Health consequences II
long term health issues
• Dysuria, implantation cysts, keloid, dyspareunia,
• recurent UTIs and VI, PIDs infertility
• dysmenorrhoea, haematocolpos, haematrometra
• Birth complications (prae-, intra, postnatal)
• Adverse psychological and sexual consequences
• De-Reinfundibulation acute/chronic consequences
https://dg-maternalhealth.de/

13. Tanner Scale of outer genital Development
The Stage of outer genital development (Vulva) is essential to
understand the Damage related to the Cutting process
The more maturated Labia minora, majora and clitoris are
the more organ related tissue can be extirpated, scared and
definitely damaged by the cutting process

14. Types of FGM
• Type 1: this is the partial or total removal of the clitoral glans (the external
and visible part of the clitoris, which is a sensitive part of the female
genitals), and/or the prepuce/ clitoral hood (the fold of skin surrounding
the clitoral glans).
• Type 2: this is the partial or total removal of the clitoral glans and the labia
minora (the inner folds of the vulva), with or without removal of the labia
majora (the outer folds of skin of the vulva ).
• Type 3: Also known as infibulation, this is the narrowing of the vaginal
opening through the creation of a covering seal. The seal is formed by
cutting and repositioning the labia minora, or labia majora, sometimes
through stitching, with or without removal of the clitoral prepuce/clitoral
hood and glans (Type I FGM).
• Type 4: This includes all other harmful procedures to the female genitalia
for non-medical purposes, e.g. pricking, piercing, incising, scraping and
cauterizing the genital area. WHO, 2020
https://www.who.int/news-room/fact-
sheets/detail/female-genital-mutilation

15. Classification
Normal female genitalia with
clitoris, labia minora and labia
majora intact.

16. Classification – Type 1 FGM
Type 1 FGM can be subtle and hard
to identify, as genitalia may look
intact.
Even in cases where minimal tissue
damage has occurred, there may still
be sensory nerve damage, and
psychological sequelae.
Type 1 FGM usually involves excision
of the clitoral hood (prepuce), with
or without excision of part or all of
the clitoris.
In some cultures it may involve a
ritual pricking or nicking of the
clitoral hood, without removal of any
tissue.

17. Classification – Type 2 FGM
Type 2 FGM is the form of female
circumcision most commonly seen.
It involves excision of the clitoris with
partial or total excision of the labia
minora. The tissue is joined in the
midline above, or just over urethra.
A Type 2 presentation can be quite
subtle and may be missed by some
practitioners when undertaking an
examination.
There may be general or peri-urethral
scarring or nerve damage, which makes
penetrative procedures uncomfortable.

18. Classification – Type 3 FGM
Type 3 FGM is the most extreme
presentation. It involves excision of
part or all of the external genitalia and
stitching/ narrowing of the vaginal
opening.
Infibulation - there will be obvious
anterior midline scar tissue.
The infibulation may obscure
underlying dermatological problems
such as abscesses, dermoid and
sebaceous cysts, and other scarring. It
may predispose to both short and
long term health consequences for
women.
In Type 3 FGM, the extent to which
genital tissue has been removed,
varies with the individual.

19. Defundibilation

20. Defundibilation sub Partu I

21. Defundibilation sub Partu II

22. https://dg-maternalhealth.de/
Flow
Chart
Women
With
FGM
Sub Partu

24. Defundibulation Procedure based on personal
Experiences
https://dg-maternalhealth.de/

39. Other Sources
Lastly my beloved father Dr Hans-Georg Grothuesmann with his overall clinical experiences and narratives and anytime
Professor Dr Karl-Ulrich Petry who inspired me to know what I am for in my professional life as medical doctor

40. Aim of my Project
Dr. Dirk Grothuesmann Consultancy
Improving Medical Services like Maternal Health, Gynecological
Services & Others by Training Health Care Providers: Relaying on
standardized training modules I teach evidence-based procedures and
related evaluation tools to local personnel in developed and developing
countries. Completing the programs offered, skills gained enable to
serve people in need in any requested setting. My approaches are
based on a economically, socially, culturally, and environmentally
sustainable foundation.
http://dg-maternalhealth.de/index2.html

41. Realizing your Path will guide you to your desired Destination, Dirk Grothuesmann

42. Dedication of this Presentation
To Ulli
likewise an African lover,
hero and light within my
medical profession

43. http://dg-maternalhealth.de/
Dr Dirk Grothuesmann
Consultancy