Correspondence Genital Mutilation/Cutting in Female Asylum-Seekers

Findings of a Survey in Berlin, 2018–2022

Female genital mutilation/cutting (FGM/C) is practiced primarily in parts of Africa, Asia, and the Middle East and has been documented in over 90 countries. According to the United Nations, more than 230 million girls and women alive today have been subjected to female genital mutilation, mostly during childhood. As a result of migration, ever more affected women are living in Germany: current prevalence data put the number of cases at approximately 104 000 (1).

FGM/C encompasses all procedures involving the partial/total removal of, or other intentional injury to, the external female genitalia for non-medical reasons. FGM/C is classified into different types, which can include, for example, the partial or complete removal of the clitoral glans and/or clitoral hood (type 1), additional excision of the labia minora and/or labia majora (type 2), and narrowing of the genital opening (infibulation, type 3) (2).

Aside from the immediate health effects that can result from poor hygiene conditions (for example, unclean cutting instruments) and the often traumatic experience of the procedure, there are also long-term complications, including recurrent bladder and urinary tract infections, cysts, infertility, birth complications, increased perinatal mortality, post-traumatic stress disorders, and the need for surgery in later life (2). In 2018, under the Council of Europe’s Istanbul Convention, Germany committed itself to providing appropriate support for women with FGM/C; since then, however, there have been virtually no systematic investigations in this regard.

The aim of our study was to gather data on the occurrence of FGM/C and its health effects among female asylum-seekers in Berlin in order to discuss possible implications for medical practice.

Methods

Between 10/2018 and 09/2022 and as part of the initial medical examination required in accordance with § 62 of the German Asylum Act, medical personnel at the initial examination center for the state of Berlin asked female asylum-seekers who were newly arrived in Berlin whether they had undergone FGM/C. Women who responded with “yes” to this question were invited to participate by means of a short structured interview which, if consented to, was immediately carried out by the examining female physician in either German, English, or via language mediation. Physical examinations for FMG/C were not performed.

The questionnaire recorded sociodemographic data (country of origin, date of birth, level of education) and a self-assessment of the type of FGM/C; here, types 1 and 2 were grouped together due to the difficulty in differentiating between them. FGM/C-related somatic symptoms such as pain on micturition and chronic pain were recorded using a visual pain scale ranging from 0 to 10, with ≥ 5 being set as the threshold score for the presence of “significant pain.” A descriptive data analysis using R 4.1.3 was performed, in which we calculated the frequency and percentages for categorical variables as well as the mean and standard deviation for continuous variables.

The study was approved by the Ethics Committee of the Charité University Hospital, Berlin (EA1/131/18).

Results

Of 15 460 women interviewed, 281 (1.8%) reported being affected by FGM/C. The main countries of origin of FGM/C-affected women were Guinea (n = 62; 22.1%), Somalia (n = 47; 16.7%), and Nigeria (n = 45; 16.0%) (Table 1).

Table 1

Sociodemographic data of screened women with FGM/C

Of the 151 women who took part in the follow-on survey, 57.0% (n = 86) had undergone type 1 or 2 FGM/C and 21.9% (n = 33) type 3; in 32 women (21.2%), it was not possible to determine the type. The most common symptoms were painful urination (type 1/2: 24.5%; type 3: 30.3%) and chronic pain in the vulvovaginal region (type 1/2: 19.9%; type 3: 21.2%) (Table 2).

Table 2

Pain and health problems according to type of FGM/C

Discussion and recommended courses of action

Although the FGM/C prevalence of 1.8% found in our study appears to be comparatively low, it is likely that some cases went unrecorded as a result of the self-reporting nature of the survey. Moreover, the women’s own classification of FGM/C type is prone to error. Nevertheless, the absolute figures point to a relevant group of women in Berlin who have undergone FGM/C. Every fifth woman with FGM/C had chronic pain in the vulvovaginal region. One in four women reported painful urination, while among women with type 3 FGM/C, the rate was as high as one in three. Comparative data are not available for Germany; however, in a US study of a group of postmenopausal women, only 5.2% reported painful urination, despite the fact that this age group is particularly susceptible to urinary tract infections (3).

The abovementioned health problems are typical reasons for consulting primary care physicians. These physicians, however, do not always have specific knowledge about FGM/C (4). Other data also suggest a need for culture-sensitive advanced training regarding FGM/C in the specialties of gynecology, obstetrics, pediatrics, and family medicine (5). In the case that patients from countries where FGM/C is practiced present for a gynecological consultation relating to some other health issue, FGM/C should be considered as a possible cause of their health problems. Recommendations on the approach to be taken with affected patients can be found on the website of the German Medical Association.

Language and cultural barriers, not to mention the vulnerability of women who have been forced to flee their countries, hamper data collection on FGM/C. Under the Istanbul Convention, Germany should ensure low-threshold access to counseling, medical examination, and treatment services for women who have undergone FGM/C.

Evelyn Kusi*, Muhammad Helmi Barghouth*, Mascha Kern, Alex Müller, Norma Bethke, Stefanie Theuring*, Joachim Seybold*

*These authors share first and last authorship, respectively.

Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Erstuntersuchungsstelle, Germany (Kusi)

Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institut für Internationale Gesundheit, Germany (Barghouth, Müller, Theuring) [e-mail]

Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institut für Public Health, Germany (Kern)

University of Cape Town, Gender Health and Justice Research Unit, South Africa (Müller)

Charité –Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Vorstand Krankenversorgung, Germany (Bethge, Seybold)

 Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript submitted on 14 June 2024, revised version accepted on 12 November 2024.

Translated from the original German by Christine Rye.

Cite this as:
Kusi E, Barghouth MH, Kern M, Müller A, Bethke N, Theuring S, Seybold J: Genital mutilation/cutting in female asylum-seekers—findings of a survey in Berlin, 2018–2022. Dtsch Arztebl Int 2025; 122: 168–9. DOI: 10.3238/arztebl.m2024.0241

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