Female Genital Mutilation (FGM)
Introduction
Female genital mutilation (FGM), also known as female circumcision (FC), but more recently as female genital mutilation/cutting (FGM/C), has taken several forms throughout all nations.
Female genital mutilation (FGM) is a term used by the World Health Organization (WHO) to describe any procedure that involves the partial or complete removal of the external female genitalia, or other damage to the female genital organs for non-medical purposes.[1] FGM is harmful to girls and women in many ways and has no health benefits. It entails removing and destroying healthy and natural female genital tissue, as well as interfering with girls’ and women’s normal bodily functions.
FGM is a violation of girls and women’s human rights that is acknowledged worldwide. It is a type of extreme discrimination against women that represents deep-seated gender inequality. It is almost always performed on minors, making it a violation of the girl child’s rights. The practice also infringes on a person’s right to health, safety, and dignity, as well as their right to be free from cruel, barbarous, inhuman, or humiliating treatment, and their right to life if the procedure results in death.
History of FGM
There is no definitive proof as to when or where FGM first occurred. Ancient Egyptian mummies have been reported of circumcised females. When Herodotus, a Greek historian, visited Egypt in the middle of the fifth century, he discovered Egyptians practiced both male and female circumcision. When a Greek geographer, Strabo, visited Egypt in 25 B.C., he observed female genital cutting as a tradition. Female circumcision was widely practiced in the late 1700s and early 1800s, according to explorers’ writings.[2]
Female genital cutting has been documented in other parts of the world for a long time, including among the Romans, who practiced it to keep their female slaves from becoming pregnant.[3]
Female circumcision process was also practiced in Africa’s tropical areas, the Philippines, Australia, and by some early Romans and Arabs, according to reports. Hysteria, epilepsy, masturbation, and mental disorders, especially those marked by compulsive sexual behavior, were all treated with clitoral circumcision in Western Europe and the United States as recent as the 1950s. Despite this, female circumcision is more common in Africa than anywhere else in the world, with at least twenty-nine countries reporting it.[4]
Epidemiology of FGM
FGM is thought to have affected an estimated 200 million girls and women alive today; however, rates of FGM are rising in tandem with global population growth. Protecting girls who are already at risk, as well as ensuring that future generations are not exposed to the risks of the practice, is a major challenge. This is particularly significant in female circumcision countries, as they tend to have high population growth and large youth populations. More than 3 million girls are thought to be at risk of FGM per year, with that figure expected to rise to 4.6 million by 2030. It is practised in countries all over the world. FGM is reported to be practised in 30 African nations, as well as ethnic groups in Asian countries, the Middle East, Eastern Europe, South America, and several western countries, such as Australia, Canada, New Zealand, the United States, the United Kingdom, and other European countries.[5]
As a result, FGM is a worldwide problem. FGM is common in Africa with varying levels of prevalence in different countries. However, because it is considered a human rights issue, there has been a lot of advocacy for its abolition.
Why are different terms used to describe FGM?
The terminology for this practice has undergone a number of changes. The procedure was initially referred to as "female circumcision" when it first gained international recognition. The word "female circumcision," on the other hand, has been criticized for drawing a comparison with male circumcision and confusing the two activities. Health experts in many countries recommend male circumcision to reduce HIV transmission; however, FGM, on the other hand, can increase the risk of HIV transmission. Some believe that the term obscures the severe physical and psychological consequences of genital cutting on women.
A large spectrum of women’s health and human rights advocates use the word "female genital mutilation." It distinguishes female circumcision from male circumcision. The word "mutilation" highlights the seriousness of the act and emphasises that it is a violation of women’s and girls’ fundamental human rights.
The word "female genital cutting" was coined in the late 1990s, possibly in response to public dissatisfaction with the term "female genital mutilation." There is concern that the word "mutilation" will be perceived as demeaning by certain cultures, or that it will suggest that parents or practitioners conduct this procedure maliciously. The term "female genital mutilation/cutting" or FGM/C, is used by some organizations to refer to both.[4]
When is FGM performed?
The age at which FGM occurs varies. FGM is most often performed on young girls between the ages of infancy and adolescence, but it is performed on adult women occasionally.
FGM can occur as soon as a few days after a child is born in some places. In certain cases, it occurs during childhood, adolescence, marriage, a woman’s first pregnancy, or shortly after the birth of her first child. According to recent statistics, the average age of FGM victims is decreasing in some regions, with the majority of FGM taking place on girls aged 0 to 15.[4]
Who performs FGM?
Traditional circumcisers perform the majority of the circumcisions, and they also play other important roles in families, such as attending childbirths. FGM is often
conducted by a nonmedical practitioner in the name of religious or cultural rituals, as well as for financial gain. It is sometimes done by medical professionals under the misguided belief that medicalizing it would minimise the risks associated with the procedure. This is known as the "medicalization" of FGM, and it is frowned upon.
When FGM is done by a health-care provider, such as a community health worker, midwife, nurse, or doctor, it is known as medicalization of FGM. Medicalized FGM may occur in a public or private facility, at a client’s home, or elsewhere. It also covers the process of reinfibulation, which can be done at any stage in a woman’s life. Reinfibulation is resuturing after delivery hence recreating a small vaginal opening.[6] Despite global efforts to end female genital mutilation/cutting (FGM/C), reinfibulation of previously mutilated or circumcised women continues in a number of countries. Reinfibulation has no advantages and is linked to complications for both the mother and the foetus. Its medicalization goes against medical ethics and should be stopped.
FGM is never safe, even if it is done in a sterile environment by a health-care professional. It can have serious health consequences both immediately and later in life. All types of FGM, including medicalized FGM, are associated with severe risks. Furthermore, there is no medical reason for FGM. Girls and women’s rights to life, physical integrity, and wellbeing are violated by trained health practitioners who conduct female genital mutilation. They’re also breaking the golden rule of medicine, which is to "do no harm". When medical staff conduct FGM, they incorrectly legitimize it as medically sound or beneficial to the health of girls and women. Furthermore, since medical practitioners often hold positions of authority and reverence in society, the practice may be further institutionalized. Furthermore, there is no evidence that a mild genital cut will help people prevent more serious forms of FGM. It worsens the case when members of a girl’s family or group are unhappy with the outcome of previous procedures, they may be subjected to FGM again.
What instruments are used to perform FGM?
Razor blades, unsterilized sharpened kitchen knives, scissors, bottles, sharpened rocks, and even finger nails have been used to execute FGM. The circumciser, or cutter, is the person who performs the operation. In most instances, an older woman performs the circumcision in the girl’s or woman’s home or at circumcision centres. Males, typically barbers, do it in some communities because of their skills with cutting tools.
These circumcisers often use a single instrument on a large number of girls, which is an unhealthy practice.
If the operation is carried out by medical professionals, they use surgical blades, pain-relieving medications and maintain the infection-prevention steps. Girls’ legs are often tied together to immobilise them for days in some cases.
Why is FGM practiced?
Female genital mutilation is a manifestation of profoundly entrenched gender disparity in every culture where it is practiced. FGM is generally accepted without question by both men and women in areas where it is commonly practiced, and anyone who does not obey the standard may face condemnation, abuse, and ostracism. Without community involvement, it can be difficult for families to give up the practice. In fact, it is often practised even though it is proven to cause harm to girls because the practice’s assumed social benefits outweigh its disadvantages.
FGM is carried out for a variety of purposes, which can be divided into five categories:
1.Psychosexual reasons:
FGM is performed for psychosexual purposes in order to regulate women’s sexuality, which is often described as insatiable if parts of the genitalia, especially the clitoris, are not removed. It is thought to increase male sexual satisfaction and ensure purity before marriage and fidelity afterward.
2.Sociocultural reasons:
FGM is considered a cultural tradition in most communities where it is practiced, which is often used as an argument for its continued practice. In some cultures, the practice’s recent adoption is attributed to the copying of neighbouring groups’ customs. FGM is seen as an integral part of a girl’s initiation into womanhood as well as a community’s cultural heritage.
3.Hygiene and aesthetic reasons:
The external female genitalia is deemed undesirable and unsightly in certain communities and is altered, presumably to improve hygiene and aesthetic appeal. FGM is linked to societal values of femininity and modesty, which include the belief that girls are clean and attractive after unclean or unfeminine body parts are removed.
4.Religious reasons:
FGM is not promoted or condoned by any religion. Despite this, FGM is seen as a religious obligation by more than half of girls and women in some countries where data is available. It has however been condemned by several religious figures.
5.Socio-economic factors:
FGM is a requirement for marriage in many communities. Economic necessity can be a significant driver of the procedure in situations where women are heavily reliant on men. FGM is sometimes a requirement for inheriting rights. It could also be a significant source of income for practitioners.
Most circumcisers or cutters receive small sums of money or gifts in exchange for their services, though some see it as a public service to their society.
In other settings, health care providers conduct FGM/C for a variety of reasons, including the mistaken assumption that the procedure is better when medicalized or for the financial benefits. One of the reasons for the difficulty in eradicating FGM is that it is a source of income with relatively large fees in countries where it is illegal.
Types of FGM
There is a wide variety of procedures conducted depending on culture, belief, and religion, and it is unknown what proportion of them is done where. In certain areas, the only thing that is now performed is a ritual that imitates FGM/C rather than real surgical procedures.
Female genital mutilation is divided into four categories:
Type 1
The clitoral glans is the external and visible part of the clitoris, which is a sensitive part of the female genitals. Partial or total removal of this part and/or the clitoral prepuce/hood (the fold of skin surrounding the clitoral glans) occurs in this type. It is also called clitoridectomy.
Type 2
In this case there is the partial or total removal of the clitoral glans and the labia minora, with or without removal of the labia majora. The inner folds of the skin of the vulva is the labia majora while the outer folds of skin of the vulva is the labia majora. Another term for this is excision.
Type 3
This is the creation of a covering seal to narrow the vaginal opening. 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/hood and glans (Type I FGM). It is commonly known as infibulation.
Type 4
This includes all other non-medical treatments that harm the female genital area, such as pricking, piercing, incising, scrapping, and cauterization.
The most prevalent types are I and II, but there are differences between countries.
Other terms related to FGM
•Incision refers to making cuts in the clitoris or cutting the clitoral prepuce free, but it also relates to incisions made in the vaginal wall and to incision of the perineum and the symphysis.
•Deinfibulation refers to the practice of cutting the sealed vaginal opening of a woman who has been infibulated, which is often necessary for improving health and well-being as well as to allow intercourse or to facilitate childbirth.
•After deinfibulation, 𝗿𝗲𝗶𝗻𝗳𝗶𝗯𝘂𝗹𝗮𝘁𝗶𝗼𝗻 is the process of stitching the external labia back together.
Complications of FGM
The complications of female genital mutilation can be classified based on various factors:
1.Time of onset:
Early complications:
severe pain
excessive bleeding
urine retention
urinary infection
infection of the wound
genital tissue swelling and ulceration
difficulty in healing of the wound
injury to surrounding tissue
shock
serious bleeding and infection can result in death.
Long-term complications:
urinary problems (painful urination, difficulty in urination, infections, incontinence)
vaginal problems (discharge, itching, pain)
menstrual problems (severe pain during menstruation, difficulty in outflow of menstrual blood)
sexual problems (low sex drive, pain during intercourse, decreased satisfaction)
increased risk of infections like HIV from either sharing of cutting instruments or genital lacerations
increased risk of childbirth complications (difficult delivery, excessive bleeding, increased need for caesarean section, need to resuscitate the baby and newborn deaths)
need for later surgeries: The sealing or narrowing of the vaginal opening (Type 3: infibulation) may lead to the practice of cutting open the sealed vagina later to allow for sexual intercourse and childbirth (deinfibulation). Sometimes genital tissue is stitched again several times, including after childbirth, hence the woman goes through repeated opening and closing procedures, further increasing both early and long-term risks
psychological problems : depression, anxiety, post-traumatic stress disorder, low self-esteem
scar tissue and keloid formation
2. Implications for various aspects of girls and women’s lives.
FGM has substantial health consequences for girls and women. The effects of FGM are dependent on a number of circumstances, including the type performed, the practitioner’s skills, the sanitary settings in which it is performed, and the girl’s or woman’s general health. Complications can arise with any kind of FGM, although infibulation is the most common.
Effect of FGM on sexual health
One of the cultural and religious justifications for FGM is the reduction of promiscuity and the preservation of virginity prior to marriage. While aiming to achieve its ostensible effect by lowering sexual drive and desire, it actually has a negative impact on a woman’s sexual life as a whole. FGM robs women of their right to sexual health and pleasure, as well as their ability to reach full psychophysical well-being. Circumcised women experience a loss in sexual desire, arousal, excitement, orgasm, and pain during sexual intercourse, among other issues. The level of sexual unhappiness among circumcised women varies according to the type of circumcision, with types II, III, and IV being more likely than type I FGM to cause sexual dissatisfaction. This is largely owing to the procedure that was carried out.
Effect of FGM on reproductive health
FGM/C has a negative impact on women’s reproductive health. Obstruction of the vaginal entrance partially or completely, causes severe menstruation discomfort and blood retention in the uterus and vagina. FGM causes infertility owing to pelvic infections or coital issues (pain and difficulty penetrating). Infibulation can cause obstructed labour and is linked to an increased risk of vaginal lacerations. Women with infibulation may need to have their vaginal opening gradually dilated before engaging in sexual activity.
Effect of FGM on childbirth
Compared to women who had not been exposed to FGM, women who had been subjected to FGM had a considerably higher chance of requiring a caesarean section, a cut during labor, serious bleeding after childbirth, an extended hospital stay, and an increased risk of maternal death. Many women who had FGM/C require their vaginal openings cut again during childbirth because they are too small to allow a baby to pass through. Women who have had infibulation are more likely to have protracted labour, which might result in delivery difficulties. Babies born to mothers who have undergone more extreme forms of FGM are more likely to die at birth or suffer serious impairments.
The WHO reported that women who had FGM had a higher infant death rate than those who did not.[7]
Women who do not give birth in hospitals are more likely to experience serious delivery difficulties and have greater neonatal unfavourable outcomes.
Effect of FGM on psychosocial health
FGM may have long-term consequences for women and girls who are subjected to it. The psychological effects of FGM vary depending on the type of procedure performed, the circumciser’s experience, and the social environment at the time of the cutting. The procedure’s psychological stress may cause behavioural problems in children, which are linked to a loss of trust and confidence in caregivers, psychological trauma from the painful procedure, feeling of humiliation from those performing the procedure, dissatisfaction genital outlook, a lack of sense of ownership over their bodies, devastating sexual life, infertility, and reproductive problems.
In the long run, the victims may develop post-traumatic stress disorder (PTSD), mood disorders with severe depression and suicidal tendencies especially in those that repress their feelings and thoughts. Sexual problems can also lead to marital issues or divorce, both of which can aggravate depression.
Effect of FGM on the economy
FGM/C costs include not only the expense of the procedures but also the cost of treating complications, particularly those related to reproductive health and childbirth.
The procedures are connected with various difficulties due to the poor surgical skills of most FGM/C practitioners, the poor sanitary practice, and the non-use of pain-relieving drugs. And efforts to repair the damage are a significant financial burden for not only the women and girls affected, but also the government and the country as a whole.
Link between FGM and the risk of HIV infection
When the same instrument is used to cut several girls, as it is done in communities where large groups of girls are cut on the same day during a socio-cultural ceremony, there is a risk of HIV transmission.
Sexual intercourse can also result in tissue laceration as a result of previous damage to the female sexual organs from FGM/C, which dramatically raises the risk of HIV infection.
Link between FGM and fistula
Fistula is an abnormal connection between two organs, in this case, the vagina and rectum or vagina and urinary bladder, resulting in leakage of faeces or urine. FGM may be associated to fistula either directly during the performance of the procedure or indirectly where it develops as a result of FGM or defibulation. FGM can result in prolonged obstructed labor, which puts one at risk for an obstetric fistula. Although no type has been directly linked to the development of a fistula, women with type III FGM have been found to present with a fistula after delivery by traditional birth attendants who may have extensively cut the infibulated genitalia and urinary bladder at the time of delivery.
Management of complications
Given the scope of these challenges, the best course of action is to avoid FGM entirely. When it has already happened, the next step in the treatment process is to deal with the patient’s specific complications. It is beneficial to develop a management protocol. This is best accomplished with a multidisciplinary, individualised strategy based on the time of presentation.
•When patients present as an emergency, prompt and skilled resuscitation treatments are critical for keeping them alive while also reducing early and long-term consequences.
•It’s critical to stop bleeding and replace the lost blood volume when it happens.
•In the case of infections, a wound swab should be taken for microscopy, culture, and sensitivity testing, and the patient should be treated with potent broad-spectrum antibiotics at first, till the sensitivity pattern indicates otherwise. There should be no delay in starting antibiotic therapy if testing facilities are unavailable.
•Psychotherapy is extremely beneficial for these women; good emotional support will help them overcome much of the challenges they face.
•Urethral catheterization with adequate analgesics will be helpful in the control of pain and urinary retention.
• At the community level, other measures include improving health services in areas where the practice is more rampant, development of emergency care, referrals to a sex therapist and attendance of birth by well-trained medical personnel.
•Having a good prediction of individuals affected or likely to suffer FGM is required in order to provide adequate care for them. The school nurse can provide educational and support services to school-aged girls who have been circumcised or are at risk of circumcision, while dedicated female teachers can fill these roles in resource poor settings.
•In some situations, referral to a gynaecologist or urologist may be required, particularly for those who may require surgery in the future.
Efforts to eliminate FGM
FGM has been linked to a variety of medical, economic, sociocultural, and women’s rights consequences, and it is currently receiving global, multidimensional attention in order to be eradicated. The morbidity and mortality associated with FGM are considerable, with no medical advantages to patients, especially in resource-poor nations where the procedure is most prevalent. As a result, for both human rights and socioeconomic considerations, its prevention and eradication are required.
The prevention of FGM stems from taking actions and measures that inhibit the emergence of risk factors through education of the public on the demerits of FGM and health awareness in places where the practice is prevalent. Reduced stigma is also vital for the early diagnosis of people affected so that they can receive prompt treatment and avoid complications. Rehabilitation of people who have developed complications is another significant aspect.
Fortunately, numerous non-governmental organizations leading the campaign are giving the prevention of FGM/C the attention it deserves on a global, local, and grassroots level.
To name a few:
WHO efforts to eliminate female genital mutilation focuses on:
•Generating proof and knowledge about the causes, consequences, and costs of the practice, as well as how to stop it and care for those who have been subjected to FGM.
•Strengthening the health sector’s response to ensure that girls and women who have undergone FGM receive the treatment they deserve while also raising awareness about the practice’s prevention. This will be accomplished by increasing advocacy for the abolition of FGM.
Efforts of United Nations’ International Children’s Emergency Fund (UNICEF) on elimination of FGM
UNICEF has an anti-FGM campaign that focuses on increasing public awareness and education as a means of addressing the source of the problem.
United Nations Family Planning Association (UNFPA) efforts
UNFPA is leading a big global initiative with other organizations to speed up the eradication of female genital mutilation (FGM), provide care for its impacts, and promote gender equality and women’s rights.
Other non-governmental organizations and various stakeholders have taken steps to eliminate all forms of female genital mutilation (FGM) and combat gender inequality by 2030, as outlined in Goal 5 of the Sustainable Development Goals (SDGs).
Conclusion
Female genital mutilation/cutting (FGM/C) is a non-therapeutic procedure in which the external female genitalia is partially or completely incised or removed. FGM/C is widespread in Africa, with varying levels of prevalence in different countries. However, because it is considered a human rights issue, there is a lot of advocacy for its abolition by mostly nongovernmental organisations. Many countries, particularly those where it has been declared illegal, underreport it. The extent of the physical and mental costs of FGM/C outweighs the procedures’ claimed benefits, underlining the need for improved multi-sectoral prevention approaches.
The responsibility for ending FGM/C does not fall solely on stakeholders and non-governmental organizations, it is a global issue that demands all hands on deck. It is not enough to have knowledge about FGM and its consequences, we must make use of that knowledge and work towards putting an end to it.
References
1.World health organisation: Female genital mutilation
https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation
2.Female Circumcision in Africa
https://www.jstor.org/stable/524569?origin=crossref&seq=1
3.Momoh C. Female Genital Mutilation. Abingdon: Radcliffe Publishing, 2005.
4.Female genital mutilation (FGM) frequently asked questions
5.Female Genital Mutilation/Cutting: A Global Concern UNICEF, New York, 2016
https://www.unicef.org/media/files/FGMC_2016_brochure_final_UNICEF_SPREAD.pdf
6.The issue of reinfibulation
https://pubmed.ncbi.nlm.nih.gov/20138274/
7.Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries
https://pubmed.ncbi.nlm.nih.gov/16753486/
8.An Overview of Female Genital Mutilation in Nigeria
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3507121/#!po=1.85185
9.Is Female Genital Mutilation an Islamic Problem?
https://www.meforum.org/1629/is-female-genital-mutilation-an-islamic-problem
10.Female genital mutilation/cutting in Africa
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5422681/#r11
Photo credit: World Health Organisation
About The Author
Dr Cynthia Chisom Edeh
Cynthia Chisom Edeh is a Medical Doctor, Writer, Content Developer and Health Awareness Creator. She is also a Girl Child Advocate and Health Volunteer.
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