Female Genital Cutting /Mutilation (FGC/FGM) continues despite Damaging Health Repercussions
Children of Kapsikumyo Primary School Kapchorwa sing against Female Genital Mutilation at Boma Grounds.

Female Genital Cutting /Mutilation (FGC/FGM) continues despite Damaging Health Repercussions


Tackling female genital mutilation from a health and cultural perspective.

By Gerald Businge
more from author >>
First published: March 19, 2007


Also Read: Should Male Circumcision be Embraced as an HIV Preventive Measure?


Sections in the article:

 

The crowd at Kapchorwa Boma grounds is clapping passionately as a woman in her fifties is being brought to the front of the pavilion to give a speech. The woman is carried aloft in a chair, which two men are carrying on their shoulders, making one wonder what kind of VIP treatment people have invented here. Yet the woman looks sad for such 'treatment'. It is only when she settles to speak that we realize that Betty Cheboi (as she introduces herself) is disabled.


Anti Female Genital Circumcision  sign post in Kapchorwa
Anti Female Genital Circumcision sign post in Kapchorwa.

About 30years ago, Cheboi says she was a healthy, agile and active young woman, married with children. She was living a happy life, until one day when the people in her village discovered she had not been circumcised as the Sabiny (people of Kapchorwa) culture demanded. According to Sabiny custom, every young girl and boy is supposed to be circumcised in a traditional rite of passage to adulthood. In December every even year, young girls and boys in Kapchorwa are circumcised after weeks of preparation that end in festivities and merry-making following the circumcision. Parents of the girls who get circumcised, especially the mothers are given gifts, ranging from goats, cows to clothes to thank them for attaining the status of getting their daughters circumcised. The community members join the family in celebrating the maturity of the girl as she has now achieved respectable status.

Cheboi recounts the events of December1976 when she was forcefully circumcised. "I remember that dreadful day as if it was yesterday," she says. "I did not want to be circumcised. I was tied up and held down while the 'cutter' did her business. It was the most appalling experience of my life," she adds resignedly. This is because the circumcision did not go well. Cheboi bled for more than two weeks, during which she experienced excruciating pain. When the wound finally did heal, Cheboi discovered that she was unable to walk. She had been paralyzed. She later leant that the story was no different from two of her village mates with whom she had been circumcised. To make matters worse, a few months after the circumcision, her husband abandoned her. "I had a life then and the circumcisers took it from me. No girl or woman should have to endure this horrific practice," she says as she concludes her message to the gathering.

This is a story many people in Kapchorwa might have heard, as Cheboi has been often called upon to tell the public about the negative effects of female genital cutting/mutilation (FGC/FGM). But, she says no one can tell the sadness brought on by the pain and deadness in her lower body that resulted from the circumcision. Cheboi like many girls in Kapchorwa and many parts of the world had to undergo circumcision because customs in their communities demanded so. While all girls who are circumcised are not as unlucky as Cheboi, according to Reproductive Education and Community Health (REACH), an NGO that is at the center of fighting female circumcision in Kapchorwa, many girls who are circumcised suffer a number of physical and psychological disorders.

What is FGM/FGC?(Back to top)
Synonymously identified as female genital cutting or female genital circumcision, "Female genital mutilation" is usually performed on girls or adolescent women. According to the World Health Organization, Female Genital Mutilation (FGM/FGC) constitutes all procedures, which involve partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or any other non-therapeutic (curative) reason. The types of procedures undertaken in female genital cutting/mutilation (FGC/FGM) can be broadly classified into four groups, ranging from the removal of a small part of the clitoris, all the way to infibulation, where the clitoris and labia minora are completely excised (cut out), the wound sewn shut, and just a small opening is left for urine and menstrual flow.

Prevalence of Female Genital Cutting (FGC) in Africa
Prevalence of Female Genital Cutting (FGC) in Africa.
Image Source: afrol.com

Where is FGM practiced?(Back to top)
FGM/FGC is practiced in more than 28 African countries, a number of Asian countries as well as some communities in South and North America as a cultural practice. The worst form of the practice, called infibulation - the removal of the external genitalia and the stitching of the vaginal opening - is common to Djibouti, Sudan and Somalia, and also is reported in Egypt, Eritrea, Ethiopia, Kenya, Mali and Nigeria. According to No Peace Without Justice, an Italian NGO working to eliminate female genital mutilation, there are now between 120 million to 130 million women worldwide who have undergone female genital mutilation. "Another two million girls and women are subjected to the practice every year, which takes place in 28 African and Arab countries, as well as by immigrant communities from these regions," the NGO says in a brief about female genital mutilation.

The Somali ethnic group in Kenya has the highest prevalence of female genital mutilation - 97 per cent of Somali women have undergone the procedure. In Egypt, 97 per cent of married women aged 15-49 have been circumcised. Some countries like the Democratic Republic of Congo and Uganda have a 5% incidence. In Uganda, female genital cutting/mutilation (FGC/FGM) is practiced among the Sabiny tribe found in the eastern district of Kapchorwa, at the foot of Mt. Elgon.

The procedure of female genital circumcision is often carried out by traditional circumcisers, often old women. In a large number of cases, it is performed in non-sterile surroundings with the girl forcibly restrained. Traditional practitioners use razor blades, knives (in some cases specially designed for the practice), and pieces of glass or scissors. According to the World Health Organisation (WHO), there have been reports of sharp stones used as cutting tools, as well as cauterization or burning. In recent years, circumcisions have also been carried out in hospitals and clinics, with doctors instead of traditional "cutters" being employed to circumcise women/girls.

This image shows the different types of FGC and how they differ to the normal female anatomy.
This image shows the different types of FGC and how they differ to the normal female anatomy.

 

Classification of female genital circumcision and how it is done(Back to top)
Type I
Excision of the prepuce with or without excision of part or the entire clitoris.
Type II
Excision of the prepuce and clitoris together with partial or total excision of the labia minora.
Type III
Excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation.)
Type IV
Unclassified

  • Pricking, piercing or incision of clitoris and/or labia
  • Stretching of clitoris and/or labia
  • Cauterization by burning of the clitoris and surrounding tissues
  • Scraping (angurya cuts) of the vaginal orifice or cutting (gishiri cuts) of the vagina
  • Introduction of corrosive substances into the vagina to cause bleeding, or of herbs into the vagina with the aim of tightening or narrowing the vagina
  • Any other procedure which falls under the definition of female genital mutilation given above.

Source: Female Genital Mutilation, Report of a WHO Technical Working Group, Geneva, July 1995

 

The new trend of female genital circumcision(Back to top)
The United Nations Population Fund (UNFPA) recently sounded an alarm against a new trend of female genital mutilation where parents are using health-care workers to perform cutting in the belief that any medical problems of female circumcision can be minimized. In an appeal for the International Day against female genital mutilation on 6th February 2007, UNFPA Executive Director, Thoraya Ahmed Obaid expressed concern about what she dubs as 'The medicalization' of the practice. She says that increasing awareness about the heath risks posed by female genital mutilation has led to more and more parents turning to health care professionals to carry out the cutting in clinical settings in the belief that it will be safer for the girl.

She warns that younger and younger girls are being subjected to the practice by their parents to reduce complaints or the possibility of refusal to participate. While the health implications of female genital mutilation are very serious and form a key component of the anti female genital mutilation campaign, many say that focusing almost entirely on the health aspects has not addressed the violation of rights or contributed to the elimination of the practice. Instead, a strong focus on health implications appears to have contributed to the adoption of less severe forms of female genital mutilation or having medical professionals carry out the procedure in a more sanitary manner. A Population Council study in 2001 found that 70 per cent of circumcised Abagusii girls in Western Kenya reported having been cut by a nurse or doctor, whereas virtually all of their mothers had been cut by a traditional circumciser.

Effects of FGC/FGM(Back to top)
The effects of FGM can vary. Not all women will experience severe ill effects like Cheboi. But many do. The WHO says that the immediate physical effects can include violent pain, backache, suppressed pain, haemorrhage, post operative shock, damage to other organs, acute urine retention, tetanus and septicaemia. HIV and Hepatitis B transmission can also occur when simultaneous operations are performed on a group of girls using the same tool(s).

Long term effects can include difficulties with sexual intercourse, menstrual problems, recurrent urinary and kidney infections, chronic infections of the uterus and vagina, infertility, acute problems during labour and birth, incontinence, prolapses, chronic vulva abscesses and difficulty in using contraceptive methods and sexual dysfunction. The psychological effects can include anxiety prior to operation, trauma, sense of humiliation, sense of betrayal by parents, severe depression, loss of sleep, nightmares and post traumatic stress syndrome.

A Survey on the Psychosexual Implications of Female Genital Mutilation on Urhobo Women of The Niger Delta Communities of Nigeria (U. J. Mukoro Department of Nursing Science, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria) shows that the practice of female genital mutilation is painful and it serves as a major source of infection on the woman on whom it is carried out. Also, the study discovered that the practice causes dyspareunia, frigidity and lack of sexual satisfaction.
(see details effects of FGM at the end of article)

History of FGC/FGM and Why it is practiced(Back to top)
The exact origin of FGC remains a mystery. The practice is known to have existed for several thousand years. However, research indicates that in the 5th Century BC, Egyptians used it as a ritual prior to marriage. Early Romans and Arabs did it for cosmetic reasons or sometimes as an indication of slavery and subordination. It is believed that the practice spread south into Africa through trade and the spread of Islam. While there is no definitive evidence documenting why or when female genital mutilation began, many theorize that it provided families a means to ensure virginity before marriage.

In some communities, female genital mutilation is seen as necessary to preserve girls' suitability for marriage and to protect the honor of the family, clan or tribe. According to WHO, female genital mutilation is also perpetuated by various myths including beliefs that the woman's clitoris would grow if left uncut potentially harming a baby in childbirth. "These beliefs increase the social pressure faced by uncircumcised women, who run the risk of isolation and ridicule in their communities or men's refusal to marry them, in societies where women depend on their husbands for their economic and social status. Families in communities which have practiced female genital mutilation for centuries, often lacking access to other points of view, usually believe that circumcision must be carried out for the girl's own good." (WHO)

FGM is deeply rooted in tradition and is supported by a wide range of beliefs and norms. It is thought by some, that female genital mutilation prevents a woman seeking sexual partners before or outside marriage, thus ensuring her fidelity as a wife. Psychosexual reasons include beliefs that a non-excised woman cannot conceive, or is not chaste. Some believe it is a form of contraceptive, while others believe it enhances fertility.

Other Sociological reasons given to support the practice of female genital mutilation include:

  • making all females equal
  • the preservation of family honour
  • the protection of girls from rape in times of war
  • increasing a girl's marriageability
  • fostering social cohesion
  • giving a girl access to resources in the community and avoiding the mockery and isolation experienced by girls who have not undergone the practice. In those communities where it is common practice, girls who have not undergone FGM are considered unclean (UNFPA).

 

FGC a gender and human rights issue(Back to top)
From a human rights perspective, female genital mutilation is a violation of women and girls' basic human rights including the right to life, the right to be protected from cruel, inhuman, or degrading treatment or punishment, the right to physical integrity, and the right to health.

Women rights activists have also attacked the practice of female genital circumcision as gender biased violence against women, and as one aimed at maintaining women as subordinates to men. They say many of the beliefs that support female circumcision are aimed at keeping women as subordinate to men as possible. In some communities in Kenya for example, women are taught that sexual pleasure is for men alone, and that showing signs of pleasure during sexual intercourse brands a woman as having "low" morals.

Beatrice Chelangat, the head of REACH in Kapchorwa says that traditionally, married women who are uncircumcised are not permitted to milk a cow and have to wait last in line for water at a well or tap. Also, a mother can only attend her son's circumcision ceremony if she herself is "clean" (circumcised). Because of these factors, some women like Cheboi who escaped female genital circumcision when they were unmarried, end up submitting to the ritual or are forced to do it during marriage.

The major debate over the years has been whether to tackle female genital mutilation from a health perspective or a cultural one. Some people have expressed concern that most anti female genital circumcision campaigns center on the health hazards of female genital circumcision, yet it is a serious cultural practice, which violates the human rights of women and children. "Health complications come after the act. We have to tackle the act as a human rights abuse," says Margaret Katono, a woman rights activist in Uganda.

Campaigns against female genital circumcision yielding results(Back to top)

 Children of Kapsikumyo Primary School Kapchorwa sing against Female Genital Mutilation at Boma Grounds
Children of Kapsikumyo Primary School Kapchorwa sing against Female Genital Mutilation at Boma Grounds.

It is this realization that shaped the anti-FGM campaign in Kapchorwa where campaigners targeted young girls in schools first (potentials to be circumcised) and the elders (as custodians of the tradition and the circumcisers/cutters). Of course the experiences by those who have undergone the circumcision, and the fact that they are openly speaking about it has helped in reducing the incidence of the dreaded practice. "I speak out against female circumcision every chance I get When I see that my words have reached them it is the only time I feel like smiling," Cheboi says. Chelangat says that after realizing that stopping female genital cutting/mutilation (FGC/FGM) is stopping an avenue for income generation and cultural merriment, the REACH project also focused their anti FGM campaign on circumcisers and the parents. The circumcisers (normally called 'cutters') are given alternative income through projects like poultry and goat rearing, while parents of the girls are given presents like cows, goats and other materials, to replace presents they would have got if they had circumcised their girls.

Detailed effects of FGM/FGC(Back to top)

Immediate Complications of the More Severe Forms of FGC/FGM
The WHO says that approximately 25 percent of infibulated women suffer from one or more of the immediate complications of female genital cutting/mutilation (FGC/FGM):

  • Agonizing pain due to lack of anesthesia
  • Haemorrhage: Amputation of the clitoris involves cutting across the clitoral artery, which has a strong flow and high pressure. Cutting across the internal pudendal artery can also cause serious bleeding. Haemorrhage may also occur after the first week as a result of sloughing of the clot over the artery, usually because of infection. If bleeding is very severe and uncontrolled, it can result in death.
  • Shock, because of the sudden blood loss and/or the unexpected pain.
  • Tetanus can occur due to the use of non-sterile equipment
  • Trauma to the adjacent structures (the urethra, bladder, anal sphincter, vaginal walls, and Bartholin's glands).
  • Acute urinary retention occurs nearly always because of 1) the pain and burning sensation of urine on the raw wound, 2) damage to the urethra and its surrounding tissue, labial adhesion or nearly complete closure of the vaginal orifice, as in infibulation.
  • Wound infection and urinary infection due to urine retention, the use of non-sterile equipment and the application of local dressings of animal feces and ashes. The infecting organisms may ascend through the short urethra into the bladder and the kidneys.
  • Fever and septicemia.
  • Group circumcisions using the same unclean cutting instruments are still common, and can spread HIV infection.
  • Eventually, death can occur due to haemorrhage or septic shock, tetanus and lack of availability of medical services or delay in seeking help.

 

Intermediate Complications

  • Delay in wound healing due to infection, malnutrition and anemia.
  • Anemia due to profuse bleeding.
  • Pelvic infection: Infection of the uterus and vagina ascending from the genital wound, and necrotising fasciitis.
  • Irregular bleeding and vaginal discharge.
  • Dysmenorrhoea due to pelvic infection, or due to the obstruction of the vaginal orifice
  • Vulvar dermoid cysts and abscesses are a very frequent complication and result from the edges of incision being turned inwards and inclusion of the epithelium. Damage to the Bartholin's duct can also lead to cysts and abscesses.
  • Formation of a keloid scar because of slow and incomplete healing of the wound and infection after the operation leading to production of excess connective tissue in the scar.
  • Dyspareunia due to the tight vaginal opening, to pelvic infection or to vaginismus.

 

Late Complications

  • Haematocolpos due to closure of the vaginal opening by the scar tissue. The menstrual blood accumulates over many months in the vagina and uterus. It appears as a bluish, bulging membrane on vaginal examination. (This occurs in less than 4% of infibulated women.)
  • Infertility because of chronic pelvic infection blocking both Fallopian tubes which is often undiagnosed and untreated. Recurrent infections can also cause miscarriages.
  • Formation of a rectovaginal fistula.
  • Recurrent or chronic urinary tract infections due to stasis of urine in the bladder and behind the scar tissue.
  • Difficulty in urinating because of damaged urethral opening or scarring over the urethral opening, or inability to completely evacuate the bladder when urinating.
  • Calculus/stone formation in bladder and in the vagina because of stasis of urine coupled with urinary infection.
  • Urinary incontinence as a complication of an over distended bladder and recurrent urinary infections. Vesico-vaginal fistula results in urinary incontinence.
  • Hypersensitivity of the entire genital area, development of a neuroma on the dorsal nerve of the clitoris.
  • Anal incontinence and anal fissure due to rectal intercourse when vaginal intercourse is not possible.
  • Transmission of HIV because of bleeding during unprotected intercourse and because of unprotected anal intercourse, or transmitted by non-sterile tools.

 

Maternal Obstetrical Complications
According to the WHO, female genital mutilation doubles the risk of the mother's death in childbirth.

  • The major obstetrical problem is prolongation of the second stage of labour because of scar or soft tissue dystocia, with the attendant need for "anterior episiotomy" (defibulation).
  • Perineal lacerations because of loss of natural compliance of the tissues.
  • Perineal wound infections and postpartum sepsis.
  • Haemorrhage, leading to shock and death because of tearing of the scar tissue.
  • Vesico-vaginal or recto-vaginal fistula: Obstructed labour can cause necrosis of the vaginal wall, because of the constant pressure of the baby's head on the posterior wall of the urinary bladder and the anterior wall of the rectum.
  • Difficulties in performing a good pelvic examination in infibulated women, resulting in the inability to effectively monitor the progress of labour.
  • Difficulty with urinary catheterization.
  • Unnecessary caesarean sections when doctors, who are not familiar with female genital mutilation, resort to caesarean section for fear of handling the infibulation scar. This introduces the risks of general anesthesia and major surgery.

 

Child Obstetrical Complications
According to the WHO, female genital mutilation increases the risk of stillbirth three to four times.

  • Prolonged, obstructed labour and lack of oxygen during the second phase of labour can result in stillbirths or children with cerebral palsy.

 

Also Read: Should Male Circumcision be Embraced as an HIV Preventive Measure?

Sources:
Toubia, Nahid (1999), Caring for Women With Circumcision: A Technical Manual for Health Care Providers, New York, Women Ink.
Women's Health in Women's Hands (1995), Female Genital Mutilation: Health effects on Girls and Women; Toronto
World Health Organization (1996), Female Genital Mutilation Infopack SERC 2000

 

By Gerald Businge
more from author >>
First published: March 19, 2007
To learn more about Ultimate Media Consult go to www.ultimatemediaconsult.com.

Gerald Businge is a media practitioner and features Editor at Ultimate Media Consult in Uganda. He is a graduate of Mass Communication and several journalism and leadership certificates. He has been a practicing journalist since March 2001 and has worked at The New Vision as features writer, and has written extensively for different newspapers, magazines, newsletters in Uganda and internationally. He currently does fulltime media communication consultancy work as well as writing and editing at Ultimate Media Consult (U) Ltd where he is a founding member and CEO. You can get his attention so long as you are interested in and you are working for a better world.