Female Genital Mutilation in Saudi Arabia: A Systematic Review

Female genital mutilation (FGM) or circumcision refers to the unnecessary procedure that damages or removes the external genitalia of females. It is mostly practiced in African countries and some Asian regions, particularly the Middle East, and is performed because of cultural, religious, and social reasons. FGM can negatively affect the lives of women and lead to devastating consequences, ranging from immediate to long-term complications. These complications can be in the physical, psychological, reproductive, or sexual health domains. In this systematic review, we aim to highlight the prevalence and practice of FGM in Saudi Arabia. We conducted a literature search at PubMed to identify studies related to the practice of FGM reported from Saudi Arabia. The results indicate that FGM can still be found in Saudi Arabia both in Saudi women and non-Saudi residents. Most of the non-Saudi women with FGM were Sudanese, Somali, Eritrean, and Egyptian. FGM is prevalent in regions such as Jeddah and Hali, Al Qunfudhah Governorate, Saudi Arabia. FGM is considered illegal in most countries around the world. However, in Saudi Arabia, there is no clear and specific law against the practice of FGM. More research on the practice of FGM in Saudi Arabia needs to be conducted to get a better grasp of the true nature of the problem in the country, which could potentially lead to specific and clear legislation that would prevent the social evil of FGM in Saudi Arabia.


Introduction And Background
Female genital mutilation (FGM) is any procedure that involves the partial or total removal of external female genitalia for nonmedical purposes [1]. This practice is frequently done by traditional circumcisers who have some role in the communities, such as birth attendants. In many areas, healthcare providers perform mutilation due to the belief that the procedure is safer when medicalized [1]. The reasons why FGM is performed differ between countries and time periods. Also, it is a mix of historical, social, and cultural factors within communities and families [1].
The World Health Organization (WHO) has classified FGM into four major types ( Table 1) [1]. The WHO estimated the costs of treating complications of FGM to be 1.4 billion US dollars during a one-year period in 27 countries in 2018 [2]. The cost is expected to be 2.3 billion in the next 30 years if the prevalence of FGM procedures remains the same [2].

Type Definition
I "Total or partial removal of the clitoral glans and/or the fold of the surrounding skin (prepuce)" II "Total or partial removal of clitoral glans and the labia minora, sometimes with that of the labia majora" III "Narrowing of the vaginal orifice, sometimes with infibulation (excision of the clitoris)" IV "Includes all other nonmedical, harmful procedures of the external female genitalia" The practice is mainly performed in multiple regions of Africa; some countries in Asia, particularly the Middle East; and among migrants from these regions [2]. It is estimated that more than 200 million women alive today have undergone FGM [2]. In addition, approximately three million females are at risk of FGM, the majority of whom are less than 15 years of age [3]. In this systematic review, we aim to highlight the prevalence and practice of FGM in Saudi Arabia.

Methods for literature search
A literature search was conducted using the PubMed database on October 1, 2021. The terms included in the search were "female genital mutilation," "FGM," and "female circumcision." In addition, to limit the search to Saudi Arabia, the terms "Saudi Arabia," "Kingdom of Saudi Arabia," and "KSA" were used (
deliveries and blood loss were more common in women who underwent delivery without defibulation. This study concluded that defibulation during delivery in women with type III FGM was a safe practice and it did reduce the risk of obstetric complications.

Saudi Arabia
Case-control study 388 There were no statistically significant differences between women (n = 388) with type III FGM who underwent defibulation during vaginal delivery and those who did not (n = 388; control group) in the duration of labor, episiotomy rates, and blood loss.  Of the participants, 18.2% (n = 175) self-reported that they had FGM. Of these, 110 were Saudis and 65 non-Saudis. More than 50% of the non-Saudis were Yemenis.
The rest of the non-Saudis were from African countries, including Sudan, Egypt, Somalia, and Ethiopia. About 25% of the women with FGM were unmarried, and the rest of the cohort was formed by married, divorced, or widowed women. About 42% of the women with FGM had a low monthly income of less than 5000 Riyals. The age at which FGM was carried out was within one week after birth in more than 50% of the women (n = 101) and at the age of 6.9 ± 0.1 years (mean ± SD) in about 25% (n =

History of Female Genital Mutilation
FGM or circumcision is an old procedure that has been practiced for centuries [5]. Multiple factors play a role in the practice of FGM, including cultural, religious, and social factors [5]. The origin of FGM is unclear. Nevertheless, it is proposed that the practice originated in ancient Egypt, as mummies from the fifth century were found to be circumcised [17]. The origin of FGM is also theorized to be slave trading, as people moved from the western regions of Africa and the western shore of the Red sea [17]. Furthermore, an extension from the Middle East to Africa by the Arab traders has also been theorized. Despite the controversy of its origin, FGM is considered a common practice worldwide [2].
The WHO stated that more than 200 million women have been affected by FGM in 2017 [2]. It is commonly practiced in the northern, eastern, and western regions of Africa [17]. In addition, several Middle East countries such as Iraq and Yemen have also been considered as common regions of FGM [6]. In Saudi Arabia, there was a belief that FGM is not common due to presumed governmental restrictions and religious prohibition [5]. However, recent studies have shown that the practice of FGM exists in Saudi Arabia [5][6][7][8][9]. Moreover, there are some quotes about FGM reported in the Islamic literature by the Prophet Mohammad (peace be upon him) [18]. The most narrated quote was " A woman used to perform circumcision in Medina. The Prophet said to her: Do not cut severely as that is better for a woman and more desirable for a husband" [18]. In the pre-Islamic era, there was occasionally a practice of partial or total removal of the clitoris. The reason for this practice in that era is unclear; however, relieving the discomfort of riding the horses or camels is a possible reason [18].

Effects and Complications of Female Genital Mutilation
FGM may have various consequences, some immediate and some arising later in life. These consequences can be related to physical, psychological, reproductive, and sexual health [19][20][21]. A questionnaire-based cross-sectional study conducted in Saudi Arabia reported that over two-thirds of the study participants were aware of the health-related complications of FGM [4]. The occurrence and severity of the adverse events due to FGM are dependent upon many factors, including the hygiene of the environment, the skills of the person performing the procedure, the resistance of the child, and how susceptible the victim is to infections [21]. FGM has been previously nicknamed "three feminine sorrows" [22]. This refers to the pain and suffering that the victim of FGM experiences during three points of her life: immediately after the procedure, during sexual intercourse, and while giving birth [22].
The immediate consequences of FGM include hemorrhage and extreme pain that may lead to shock and loss of consciousness and even death [21]. Women who undergo FGM usually have their legs bound for a period after the procedure, leading to the restriction of fluid drainage and thus increasing the chances of infection of the female reproductive system and the urinary tract, as well as leading to chronic kidney disease and poor wound healing [21]. Furthermore, damage to adjacent tissues and structures such as the urethra is not uncommon, and the damage to these structures may lead to long-term consequences such as urinary retention, recurrent urinary tract infections, and epidermal inclusion cysts [9,12,21]. Epidermal inclusion cyst is not a rare complication of FGM [12]. A study revealed that 21 patients who underwent type I FGM presented with a mass in the vulva that was diagnosed as an epidermal clitoral cyst secondary to type I FGM [14]. Another complication secondary to FGM is a case of a completely closed vagina. It was reported from King Abdulaziz University Hospital, Jeddah. The patient was a 16-year-old Eritrean who complained of urinary retention that was associated with a history of recurrent urinary tract infections [10].
Sexual dysfunction is commonly associated with FGM, and the degree of the dysfunction increases with the severity and extent of the mutilation [9]. However, a study published in 2010 showed that even type I and type II FGMs are associated with sexual dysfunction [13]. The sexual dysfunction arising from FGM is found to be across all sexual domains such as libido, arousal, orgasm, satisfaction, lubrication, and pain [9]. The clitoris is believed to be the most important organ in female sexual health, and most FGM procedures involve the mutilation of this critical organ [1,23]. Obstetric complications frequently occur in patients with FGM, and these complications include postpartum hemorrhage, genital tract trauma, and perineal tearing [24]. FGM is also associated with increased rates of Cesarean section and extended maternal hospital stay [24,25]. In addition, a study revealed an increased incidence of vaginal candidiasis in circumcised women compared with the control group [16]. However, a study based in Australia showed that females with FGM had similar obstetric outcomes to females without FGM, except that the FGM group had a higher risk of Cesarean section and first-and second-degree perineal tears [26]. This might indicate that the hospital facilities and expertise of the staff have an influence on the outcomes of delivery in women with FGM. Furthermore, a procedure in which the small vaginal opening is cut open, known as defibulation, is required for patients with type III FGM to facilitate an unobstructed birth [11,15]. A recent study published in 2020 suggested that defibulation reduces the incidence of obstetric complications in women with type III FGM [6].
The procedure of FGM can be very traumatizing, especially if done at a young age. Posttraumatic stress disorder, depression, and anxiety have been frequently documented to be associated with FGM [27][28][29]. The feeling of being betrayed, wanting to cry, and being lonely along with sleep disturbances and headaches were also frequently reported [29]. However, more studies need to be conducted to study other associated factors such as physical and sexual violence.

Female Genital Mutilation in Saudi Arabia
The practice of FGM for reasons that are not related to medical treatment has been widely spread over the years, affecting females particularly in the region of Africa and the Middle East [9]. In a study performed at King Abdulaziz University Hospital in Jeddah [7], it was concluded that FGM is being practiced among both Saudi and non-Saudi women residing in Jeddah. The study included 963 women between the ages of 18 and 75 years from Saudi and other countries, mainly Yemen, Sudan, Egypt, Somalia, and Ethiopia, with the majority of them being Muslims (79.1%). The study showed that 18.2% of the participants had FGM. Those who had FGM were older and married and had lower monthly income compared with those who did not undergo FGM. Moreover, FGM practice was less common among Saudi women compared with the other nationalities residing in Saudi Arabia. Furthermore, the study indicated that the nationality and the age at which FGM took place had an association as women with Saudi nationality performed FGM at an earlier age compared with women from other nationalities [7].
Another study conducted in Hali, Al Qunfudhah Governorate, Saudi Arabia, was based on a community household survey to detect the prevalence of FGM in females who are ≤18 years old [8]. The study concluded that FGM is still rooted in the culture of people in rural and semi-urban areas. Based on the Hali official map, the region was divided into 30 clusters. The survey was directed to 12 houses in each cluster and covered 218 females. The results showed that the majority of females had their circumcision performed at seven years of age or less (59.4%). Female circumcision was mostly done by doctors (91.4%). Circumcision was less common in females whose parents had better education and good income and were unrelated and whose mothers got married at an older age. However, the differences were statistically insignificant [8].

Forensic and Legal Aspects of Female Genital Mutilation
Given that FGM has no real benefit and can lead to devastating complications both in the short term and long term as discussed earlier, it is not surprising that it is illegal in most countries around the world. The United States, for example, and the United Nations consider FGM to be a crime and a violation of human rights. People who are charged with the offense of committing FGM in these countries can face serious consequences and might serve time in prison [30]. Furthermore, even in countries where it is technically not illegal, it is heavily frowned upon and constantly faces criticism from the media. Multiple protests and calls for action are continuously being carried out to ban the evil practice of FGM across the world. For instance, the "28 Too Many" is a charity organization based in England and Wales that aims to help implement and enforce laws against the practice of FGM in 28 African countries [31].
The practice of FGM in Saudi Arabia is controversial yet rarely addressed. Some claim that it only exists in some parts of the southern regions of the country, and others claim that it is present in all regions. Part of the controversy stems from the fact that there is no clear and specific law against FGM in Saudi Arabia. However, hospitals and clinics across the country do not perform FGM, at least not officially. On the other hand, most victims of FGM report that the procedure was done by medical professionals [7,8]. The issue of the law being unclear regarding the practice of FGM is not limited to Saudi Arabia since neighboring countries such as the United Arab Emirates also share this predicament [32].
Further nationwide research regarding FGM needs to be conducted in Saudi Arabia to determine the prevalence and actual impact of FGM at the national and subnational levels, as well as to determine whether this practice is different or not, compared with other countries where FGM is practiced. In addition, more research is needed to focus on the social perspective of FGM and whether there is a social norm regarding FGM that affects the decision of the victims of FGM to undergo such practice in Saudis and non-Saudis residing in Saudi Arabia. Furthermore, the information gained from such studies would provide guidance to decision-makers about the nationwide prevalence of FGM and, most importantly, to construct a legal change to enact clear and specific laws against the practice of FGM in Saudi Arabia.

Conclusions
FGM has been in practice for centuries in many countries around the world. It is associated with multiple serious complications that in severe cases might even lead to death. The United Nations considers FGM as a violation of human rights, as it might lead to various physical, psychological, and sexual adversities.
Although FGM is illegal in many countries, there are no clear and specific legal restrictions regarding the practice of FGM in Saudi Arabia. It was thought that FGM is not common in Saudi Arabia; however, recent studies show that it is prevalent in Jeddah and Hali in the western region of the country. Understanding the significance of FGM from the medical, psychological, and social perspectives might spot the light on clear and specific legislation preventing the practice of FGM in Saudi Arabia. To do so, nationwide studies regarding the practice of FGM need to be conducted in Saudi Arabia to determine the prevalence and actual impact of FGM at the national and subnational levels, as there are limited studies addressing this issue.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.