Female genital mutilation - caring for patients and child protection
Background and introduction Definitions
Female genital mutilation (often referred to as “FGM”) is a collective term used for a range of practices involving the removal or alteration of parts of healthy female genitalia. Different degrees of mutilation are practised by a variety of cultural groups in the UK. Circumcision involves the removal of the head of the clitoris, with the body of the clitoris left intact, although this term is often euphemistically used to cover a range of forms of mutilation. The two most common forms of mutilation are excision and infibulation. Excision involves total or partial removal of the prepuce, clitoris and/or labia minora. Infibulation is the total amputation of all of the external genitalia together with the stitching together of the remainder of the labia majora leaving only a matchstick-sized opening for the passage of urine and of menstrual blood. Other mutilations include pricking, piercing or stretching of the clitoris and/or labia, cauterisation by burning of the clitoris and surrounding tissues, scraping of the vaginal orifice or cutting of the vagina, and introduction of corrosive substances into the vagina to cause bleeding or herbs into the vagina with the aim of tightening or narrowing it. The age at which such procedures are carried out varies from a few days old to just before marriage.
All forms are mutilating and carry serious health risks. Female genital mutilation is not comparable with male circumcision, over which there is no consensus about the health risks and potential benefits.[reference 2]
Prevalence
Today, the number of girls and women world-wide who have undergone genital mutilation is estimated at between 100 and 140 million, with at any one time a further 2 million girls at risk of mutilation.[reference 3] It is found in 28 African countries, and also in South East Asia and the Middle East. The highest prevalence rates, of 98% or more, are found in Djibouti, Guinea and Somalia.[reference 4] Eritrea, Mali, Sierra Leone and Sudan have very high prevalence rates, all around 90%.[reference 5] It is also found in Europe and elsewhere amongst communities originating from these parts of the world. There is however evidence that in some countries the practice is declining. In 9 out of the 16 countries in which Development and Health Surveys (DHS) [reference 6] have collected data (Benin, Burkina Faso, Central African Republic, Eritrea, Ethiopia, Kenya, Nigeria, Tanzania and Yemen), a marked decrease in prevalence in the younger age group (15-25 years of age) is demonstrated. In the remaining 7 countries (Côte d’Ivoire, Egypt, Guinea, Mali, Mauritania, Niger and Sudan) prevalence is roughly equal for all age groups, suggesting that rates of FGM in these cases have remained relatively stable over recent decades. [reference 7] Changes in prevalence can also be assessed in countries where two or more Development Health Surveys have been carried out. In countries where comparison is currently possible there has been a clear decrease in overall prevalence in Eritrea, Kenya and Nigeria, whilst there has been an increase in Burkina Faso and Côte d’Ivoire. [reference 8]
In November 2003 an international agreement was reached on appropriate indicators for monitoring FGM at the UNICEF consultation on indicators conference. [reference 9] Through the standardisation of indicators the potential for collecting accurate and comparable data on FGM worldwide is greatly enhanced. Such data is important for accurate situational analysis of FGM and monitoring progress towards ending the practice worldwide. [reference 10]
Health risks
Mutilation has immediate risks, including severe pain, haemorrhage, tetanus and other infections, septicaemia or even death. These consequences are worsened when traditional “circumcisers”, who may be brought by immigrants to the UK from their home country, work in unsterile conditions without anaesthesia.
In the longer term, women experience problems with their sexual, reproductive and general health. They may have difficulty with voiding or menstruating, and be prone to fistula and keloid formation, recurrent urinary tract infections or pelvic infections. These may leave women infertile and others who do conceive are likely to experience difficulties with childbirth due to a scarred birth canal. This increases the risk of stillbirth or haemorrhage from internal tearing which may lead to maternal death.
One of the most comprehensive studies into FGM and obstetric outcomes was published in June 2006 by the World Health Organisation (WHO). The research shows a causal relation between obstetric complications and the type of mutilation suffered – the more brutal the mutilation, the worse the complication. According to the research, women who have undergone FGM are more likely to have a caesarean delivery, have up to 66 per cent chance of having a baby that requires resuscitation and are 55 per cent more likely to have a child who dies before or shortly after birth. [reference 11]
Little is documented about the psychosexual and psychological sequelae of female genital mutilation. Sexual sensitivity may be reduced after mutilations that remove the clitoris or leave large areas of tough scar tissue in place of sensitive genitals. Narrowing of the vaginal opening can make intercourse painful for both partners. Long term consequences might also include behavioural disturbances as a result of the childhood trauma and possible loss of trust and confidence in carers who have permitted, or been involved in, a painful and distressing procedure. It is also reported that women may have feelings of incompleteness, anxiety and depression, and suffer chronic irritability, frigidity, marital conflicts, or even psychosis.[reference 12]
Many health professionals in the UK will not be familiar with the sequelae of female genital mutilation. Specialist medical procedures, obstetric care, counselling and psychotherapy may all be required.
Motivation
The reasons given to justify female genital mutilation are numerous and it has not been possible to determine when or where it originated. The reasons cited generally relate to tradition, power inequalities and the ensuing compliance of women to the dictates of their communities. In sociological studies, the World Health Organization (WHO) reports that the following reasons have been given for female genital mutilation: custom and tradition; religious demand; purification; family honour; hygiene (cleanliness); aesthetic reasons; protection of virginity and prevention of promiscuity; increasing sexual pleasure for the husband; giving a sense of belonging to a group; enhancing fertility; and increasing matrimonial opportunities.[reference 13] The belief that female genital mutilation is demanded by some religions is erroneous.[reference 14]
Many women believe that their circumcision, excision or infibulation is necessary to ensure acceptance by their community and they are unaware that these traditions are not found in most of the world. Those who practice female genital mutilation may often believe in it without perceiving all its repercussions. Attitudes are gradually changing, however, in communities that practice it, particularly among some urban educated men and women. Many members of the communities in the UK affected by female genital mutilation are strongly opposed to the continuation of the practice and have expressed serious concerns about the welfare of women and girls living in Britain who are likely to be mutilated. Doctors practising in multicultural environments can offer valuable support to those members of ethnic communities who seek to eliminate female genital mutilation.
Medicalization
It is sometimes argued that, as it would minimise some of the health risks, female genital mutilation should be done by doctors, in sterile conditions with anaesthesia. This argument cannot be easily dismissed in the light of accounts of the alternative being mutilation by elderly women using crude tools such as knives, scissors, scalpels, pieces of glass or razor blades, in poor light and septic conditions. Nevertheless, most international organisations and national medical associations, including the BMA, agree that health professionals should not carry out female genital mutilation and that the practice constitutes a clear breach of human rights. The World Health Organization considers that “the medicalization of the procedure does not eliminate this harm and is inappropriate for two major reasons: genital mutilation runs against basic ethics of health care whereby unnecessary bodily mutilation cannot be condoned by health providers; and, its medicalization seems to legitimise the harmful practice”.
Support for eradication
The urgent and unqualified need to eradicate all forms of female genital mutilation is being pursued at all levels, from campaigns by international organisations, to groups of women refusing to have their daughters mutilated. In 1997, the World Health Organization, the United Nations Children’s Fund, and the United Nations Population Fund issued a statement noting that whilst female genital mutilation continues as a deeply rooted traditional practice, culture is in constant flux and is capable of adapting and reforming.[reference 15] A successful programme to reduce the prevalence of female genital mutilation is happening in Kenya, where an initiation ceremony of “circumcision through words” leads to young women’s right of passage to adulthood.[reference 16] It includes education in schools, community outreach programmes involving men as well as women, and teaching girls, their mothers, fathers, aunts and godmothers about the advantages of this new approach.
In July 2003, the African Union adopted a Protocol to the African Charter on People's and Human Rights in Maputo, Mozambique. The Maputo Protocol covers a broad range of women’s rights, including the elimination of discrimination against women, the right to dignity, the right to life, the integrity and security of the person, the right to education and training, economic and social welfare rights and health and reproductive rights. Article 5 of the Protocol requires that all forms of female genital mutilation be condemned and prohibited. The protocol has since been ratified by 15 member states and in September 2004 an international conference was hosted in Kenya which focussed on developing a political, legal and social environment for the implementation of the protocol. Across Africa and the Middle East many countries have also passed explicit legislation making FGM illegal, either by statute or degree, including Senegal, Burkina Faso, Egypt, Guinea, Tanzania, Côte d’Ivoire, the Central African Republic, Djibouti, Ghana, Benin, Kenya, Niger, and Togo.
Individual doctors have an important role to play in efforts to eradicate female genital mutilation. They can work as part of inter-agency teams to change opinion amongst communities where it is practised. Doctors can also raise awareness of the harmful effects of female genital mutilation, amongst the public, medical professionals, decision-makers, governments, political, religious and village leaders, as well as traditional healers and birth attendants. Unfortunately, evidence presented to the BMA’s human rights steering group that worked in the late 1990s showed that in some areas health professionals pointing out the health risks of mutilation have been targeted for reprisals by traditionalists. The role of doctors in preventing and speaking out about abuses of human rights is the subject of the BMA’s book 'The medical profession and human rights'.[reference 17]