General question:
Why African women undergo female genital mutilation despite the danger of the practice?
Yes. Women do get circumcised as suggested by the widely-accepted term. But, although some coin it as desexualizing since feeling sexual pleasure in her life is lessened. It isn't a matter of snipping a little skin it is a total mutilation of her entire vagina starting with the removal of the clitoris which makes her unable to ever experience orgasm which some believe to be far from the actual definition of circumcision as to that of a male.
Procedures:
World Health Organization Categorization
FGC consists of several distinct procedures. Their severity is often viewed as dependent on how much genital tissue is cut away. The WHO—which uses the term Female Genital Mutilation (FGM)—divides the procedure into four major types although there is some debate as to whether all common forms of FGM fit into these four categories, as well as issues with the reliability of reported data.
Diagram 1: This image shows the different types of FGM and how they differ to the uncircumcised female anatomy.
Type I
The WHO defines Type I FGM as the partial or total removal of the clitoris (clitoridectomy) and/or the prepuce (clitoral hood); see Diagram 1B. When it is important to distinguish between the variations of Type I cutting, the following subdivisions are proposed: Type Ia, removal of the clitoral hood or prepuce only (which some view as analogous to male circumcision and thus more acceptable); Type Ib, removal of the clitoris with the prepuce. In the context of women who seek out labiaplasty, there is disagreement among doctors as to whether to remove the clitoral hood in some cases to enhance sexuality or whether this is too likely to lead to scarring and other problems.
Type II
The WHO's definition of Type II FGM is "partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. When it is important to distinguish between the major variations that have been documented, the following subdivisions are proposed: Type IIa, removal of the labia minora only; Type IIb, partial or total removal of the clitoris and the labia minora; Type IIc, partial or total removal of the clitoris, the labia minora and the labia majora.
Type III: Infibulation with excision
The WHO defines Type III FGM as narrowing of the vaginal orifice with creation of a covering seal by cutting and repositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation)." It is the most extensive form of FGM, and accounts for about 10% of all FGM procedures described from Africa. Infibulation is also known as "pharaonic circumcision".
In a study of infibulation in the Horn of Africa, Pieters observed that the procedure involves extensive tissue removal of the external genitalia, including all of the labia minora and the inside of the labia majora. The labia majora are then held together using thorns or stitching. In some cases the girl's legs have been tied together for two to six weeks, to prevent her from moving and to allow the healing of the two sides of the vulva. Nothing remains but the walls of flesh from the pubis down to the anus, with the exception of an opening at the inferior portion of the vulva to allow urine and blood to pass through; see Diagram 1D. Generally, a practitioner recognized as having the necessary skill carries out this procedure, and a local anesthetic is used. However, when carried out "in the bush", infibulation is often performed by an elderly matron or midwife of the village, without sterile procedure or anesthesia.
A reverse infibulation can be performed to allow for sexual intercourse or when undergoing labor, or by female relatives, whose responsibility it is to inspect the wound every few weeks and open it some more if necessary. During childbirth, the enlargement is too small to allow vaginal delivery, and so the infibulation is opened completely and may be restored after delivery. Again, the legs are sometimes tied together to allow the wound to heal. When childbirth takes place in a hospital, the surgeons may preserve the infibulation by enlarging the vagina with deep episiotomies. Afterwards, the patient may insist that her vulva be closed again.[29]
Women who have been infibulated face a lot of difficulty in delivering children, especially if the infibulation is not undone beforehand, which often results in severe tearing of the infibulated area, or fetal death if the birth canal is not cleared (Toubia, 1995). The risk of severe physical and psychological complications is more highly associated with women who have undergone infibulations as opposed to one of the lesser forms of FGM. Although there is little research on the psychological side effects of FGM, many women feel great pressure to conform to the norms set out by their community, and suffer from anxiety and depression as a result (Toubia, 1995). "There is also a higher rate of post-traumatic stress disorder in circumcised females" (Nicoletti,
A five-year study of 300 women and 100 men in Sudan found that "sexual desire, pleasure, and orgasm are experienced by the majority (nearly 90%) of women who have been subjected to this extreme sexual mutilation, in spite of their being culturally bound to hide these experiences."[32]
Type IV: Other types
There are other forms of FGM, collectively referred to as Type IV that may not involve tissue removal. The WHO defines Type IV FGM as "all other harmful procedures to the female genitalia for non-medical purposes, for example, pricking, piercing, incising, scraping and cauterization." This includes a diverse range of practices, such as pricking the clitoris with needles, burning or scarring the genitals as well as ripping or tearing of the vagina. Type IV is found primarily among isolated ethnic groups as well as in combination with other types.
Revised classification
This classification has been modified since 1996 but still retains the basic division into four types, as set out in a WHO “Fact Sheet”:
Female genital mutilation is classified into four major types:
Female genital mutilation is classified into four major types:
- Clitoridectomy: partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, rarely, the prepuce (the fold of skin surrounding the clitoris) as well.
- Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are “the lips” that surround the vagina).
- Infibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, and sometimes outer, labia, with or without removal of the clitoris.
- Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.
How did this tradition come to be?
The history of female circumcision, also known as female genital mutilation (FGM), has been traced back as far as the 2nd century BC, when a geographer, Agatharchides of Cnidus, wrote about female circumcision as it occurred among tribes residing on the western coast of the Red Sea (now modern-day Egypt). Based on current geographic locations of FGM, the practices seems to have originated in Egypt and has spread south and west.The practice of female genital mutilation/circumcision was told to date back to ancient times.
Female circumcision has existed for over 4,000-5,000 years originating in a period predating God’s covenant with Abraham to circumcise his people. The practice began in Egypt and was frequently performed by the ancient cultures of the Phoenicians, Hittites, and the ancient Egyptians. The practice of female circumcision soon migrated to the Red Sea coastal tribes and the Arab traders and then eventually to eastern Sudan. Today the practice has barely waned in some of the modern day Moslem and African civilizations and with the increase of migrants from such areas; the primitive tradition has reached the coasts of America, Europe, Australia and Canada. It is estimated that over 120 million women have undergone the procedure worldwide and that between 4 and 5 million cases of female genital mutilation occur annually in infant girls and women.
Some also believe that female circumcision was rooted in the Pharaonic belief in the bisexuality of the gods. According to this belief, mortals reflected this trait of the gods; every individual possessed both a male and a female soul. The feminine soul of the man was located in the prepuce of the penis; the masculine soul of the woman was located in the clitoris. For healthy gender development, the female soul had to be excised from the man and the male soul from the woman. Circumcision was thus essential for boys to become men and girls to become women. This tradition was continued to some Islamic countries while banned from most of the nations from all-over the world due to the harm it causes.
What does this tradition mean for Africans?
Although it may sound irrational, to those who have undergone this practice the main, and mostly their only reason is because it is part of their tradition.
FGM is a social custom, not a religious practice. This is mostly done by Muslims who base this unlikely tradition to a religious background and is often justified by a controversial saying attributed to the Prophet Mohammed that seem to favor sunna circumcision involving minor cutting of the clitoris. The authenticity of these sayings are unconfirmed, and some scholars have refuted them. Even if true, they only permit the practice; they do not mandate it.FGM has probably been performed for at least 1,400 years (some references estimate 2,000 years), and started during what Muslims call "al-gahiliyyah" (the era of ignorance). The Qu'r'an, Hebrew Scriptures (Old Testament) and Christian Scriptures (New Testament) is silent on the subject. The Sunnah (the words and actions of the Prophet Mohammed) contains a reference to female circumcision.
The importance given to virginity and an intact hymen in these societies is the reason why female circumcision still remains a very widespread practice despite a growing tendency, especially in urban Egypt, to do away with it as something outdated and harmful. Behind circumcision lies the belief that, by removing parts of girls' external genitals organs, sexual desire is minimized. This permits a female who has reached the dangerous age of puberty and adolescence to protect her virginity and therefore her honor, with greater ease. Chastity was imposed on male attendants in the female harem by castration which turned them into inoffensive eunuchs. Similarly female circumcision is meant to preserve the chastity of young girls by reducing their desire for sexual intercourse.
It is a patriarchal practice, even though it’s so dominant in the culture that the people, who perpetuate it, a lot of the time, are women, just like in many cultures women do things to themselves to keep up with the cultural definition of what femininity is about. A lot of people make the comparison with how women mutilate themselves whether they do plastic surgeries on their faces or their breasts; sometimes in Western cultures they do plastic surgeries on their genitals for reasons also of cosmetics. Admittedly, these are adult women who, rightly or wrongly, have the right to do what they like to themselves. That’s very different from doing things to children. We have to make that distinction very clear. The idea behind this idea is that women are never whole, they’re never complete, they can’t be who they are, they have to be changed and mutilated and cut to fit some accepted male-dominated prescription of what women should be like.
This is also commonly held belief which states that circumcision prevents girls from falling in sin and ensures girls’ purity and proper behavior. Most men are away at work long hours and believe that if their wives are circumcised they will not be tempted do anything bad while staying at home in the villages. It is generally believed that if a girl is not circumcised she will be impolite and disobedient. For these reasons it might be difficult for an un-circumcised girl to marry since the husband or husband’s family might prefer a circumcised girl to be sure that she is well-behaved.
Many women believe that what are cut are outgrowths of the female genital organ without any functions or purposes. Some people believe that if women are not circumcised, their genitals will grow and become like a man’s, and the girl will not develop a feminine body. It happened that girls who did not have a clear understanding of what FGM is asked to be circumcised like their friends. Many people also believe that female circumcision is required by their religions.
Many women believe that what are cut are outgrowths of the female genital organ without any functions or purposes. Some people believe that if women are not circumcised, their genitals will grow and become like a man’s, and the girl will not develop a feminine body. It happened that girls who did not have a clear understanding of what FGM is asked to be circumcised like their friends. Many people also believe that female circumcision is required by their religions.
But, just like any other thing, there are also women who have undergone these even if they are against the act.
Below is a list of different reasons for undergoing this custom.
Factors Responsible for Female Genital Mutilation
(a) Historical Factor
The historical basis of Female Genital Mutilation could be traced to the biblical account of the
covenant between God and Abraham as recorded by the Holy Bible where God instructed that every
male of Abraham and his generations be circumcised37. It is salient to observe that this biblical account
does not include female in the list of human beings ordained by God to be circumcised. As early as the
17th century, there were attempts by Christian missionaries and colonial administrators in Africa to
prevent the practice38. The international interest which aroused about Female Genital Mutilation led to
the first International Conference organized by the World Health Organization (WHO) in Khartoun,
Sudan in 1979.
Even though Sudan had not been adjudged through various studies and research works to be the
African nation where the practice started; it could be argued that the nation is one of the oldest centers
of Female Genital Mutilation since it was the first nation in Africa to legislate against the practice in
194639. Beginning from 1970s, many non-governmental organizations and a number of
intergovernmental and governmental bodies have been actively involved in raising awareness about
Female Genital Mutilation as well as developing strategies for its eradication.
(b) Cultural Factor
Culture amounts to the customs, beliefs, arts, way of life and social organization of a particular country
or group of people40. In Africa, the preponderance of evidence establishing culture as one of the factors
for Female Genital Mutilation in different ethnic groups is that people have a resolute belief that
women’s unmutilated genitals are ugly and bulky. That a woman’s genitals can grow and become
unwieldy, hanging down between her legs unless the clitoris is excised41. It is also believed that a
woman’s clitoris is dangerous and that if it touches a man’s penis he will die. Similarly, if the baby’s
head touches the clitoris during childbirth, the baby will either die but if it manages to survive, he or
she may not succeed in life42.
In Kenya, customs and traditions are the most frequently cited reasons for Female Genital
Mutilation. It was even said that the former President of that nation, Jomo Kenyatta, asserted that
Female Genital Mutilation was an inherent part of the biggest ethnic group in Kenya (the Kikuyu
tribe), to the extent that abolition of it might destroy the tribal system43. Also, other Female Genital
Mutilation – practicing societies like Sierra-Lieone, Ghana, Gambia, Liberia, Sudan, Egypt, Togo,
Pakistan, India, Turkey, Malaysia etc. regard the age-long phenomenon as so normal that people
cannot imagine a woman or a girl who has not undergone it to be considered an adult44.
In Nigeria, most of the people in the tribes involved in the practice believe that Female Genital
Mutilation is a cultural inheritance designed to preserve some traditional values such as religious
purification, family honour, protection of virginity, prevention of promiscuity, increasing sexual
pleasure for the husband and enhancing fertility45.
(c) Social Factor
The subject of sociology is predicated on the nature and development of the society. In considering
social factor as one of the foundation elements for the practice of Female Genital Mutilation in
different societies, it would have been ideal to see the practice in the context of each society, the way it
is organized and the behaviour of its people. However, in view of the fact that so many societies are
involved in the practice, a method of adopting an holistic view of outstanding features of the social
factor common to many jurisdictions is preferred in this article.
In most traditional societies in Africa, Female Genital Mutilation is often deemed necessary in
order to make a girl a complete woman while the practice itself is seen as marking the divergence of
the sexes in terms of their future roles in life and marriage46. The removal of the clitoris and labia
which is thought by some tribes as the ‘male parts of a woman’s or girl’s body’ is believed to enhance
her feminity so necessary to pave a way for docility, obedience and total submission to her husband.
In certain African and Asian cultures, Female Genital Mutilation is usually carried out as part
of an initiation ceremony during which the woman or girl may be taken to a special designated place to
recover while some traditional teachings are imparted47. In some places too, the practice is associated
with festivities, gifts and rituals at the end of which the woman or girl will be considered as becoming
an adult, brave, ready to face challenges of life and acceptable to the community48.
(d) Illiteracy
The word ‘illiteracy’ in English Language is traditionally translated to mean inability to read and write,
or without much education. In the context of this article, illiteracy is also to be seen as a situation
where a person could be well educated, able to read and write but not knowing much or anything at all,
about a particular matter. Illiteracy as a serious factor responsible for persistent Female Genital
Mutilation particularly in the developing countries of Africa, Asia, Caribbean and Middle-East,
manifests principally in the inability of millions of people to read and write. Such people might not
have been slightly opportuned to go to school. They therefore, grow up in their traditional societies,
glued to their customs, never mixed with people from other enlightened societies and so, not ready to
forsake their culture and patterns of existence.
Another category of persons are those who may either be illiterates or literates but lack any
knowledge about Female Genital Mutilation, its harmful medical or sociological effects and volumes
of campaigns for its eradication.
One other interesting category of persons consists of literates who know much about the
practice but feel strongly that since a people’s culture determines their fate and existence, they are free
to practice what God had given to them so long as their faith, belief and confidence remain unshakable
in it. Some of these persons also assert that the latest complaints about harmful effects of Female
Genital Mutilation originated from advanced Western nations as a ploy to condemn and defame the
age-long tradition of other developing nations. In fact, Dr. Nowa Omoigui, a medical doctor in South
Carolina, USA, described the current debate as a “western judgment which must not be rushed to
implement but will have to be slowed down at some point”49.
In view of the above, there is an extent to which illiteracy can actually be capitalized upon as a
serious factor for the prevalence of Female Genital Mutilation in various societies without looking
deeply at the socio-economic and cultural settings of the people concerned. Even if the so called
illiterates suddenly become literates today, what is the likelihood that they will relinquish the practice?
The nexus between human rights and Female Genital Mutilation can be well appreciated in terms of
their interactive effects on the rights of women and girl folks in many societies with Nigeria in focus.
Other uncategorized reasons were also listed such as those with no scientific basis and pure superstations.
§ Bad genital odors can only be eliminated by removing the clitoris and labia minora.
§ FGM prevents vaginal cancer.
§ An unmodified clitoris can lead to masturbation or lesbianism.
§ FGM prevents nervousness from developing in girls and women.
§ FGM prevents the face from turning yellow.
§ FGM makes a woman's face more beautiful.
§ If FGM is not done, older men may not be able to match their wives' sex drive and may have to resort to illegal stimulating drugs.
§ An intact clitoris generates sexual arousal in women which can cause neuroses if repressed.
§ The fear of AIDS has been used by both sides of this issue. Shiek Badri stated in 1997-JUN: "Those who are not circumcised get AIDS easily" But opponents to the practice sometimes claim that AIDS is spread by the unhygienic practices during the procedure itself.
§ FGM is often motivated by beliefs about what is considered proper sexual behaviour, linking procedures to premarital virginity and marital fidelity. FGM is in many communities believed to reduce a woman's libido, and thereby is further believed to help her resist "illicit" sexual acts. When a vaginal opening is covered or narrowed (type 3 above), the fear of pain of opening it, and the fear that this will be found out, is expected to further discourage "illicit" sexual intercourse among women with this type of FGM.
§ FGM is associated with cultural ideals of femininity and modesty, which include the notion that girls are “clean” and "beautiful" after removal of body parts that are considered "male" or "unclean".
§ Though no religious scripts prescribe the practice, practitioners often believe the practice has religious support.
§ Religious leaders take varying positions with regard to FGM: some promote it, some consider it irrelevant to religion, and others contribute to its elimination.
§ Local structures of power and authority, such as community leaders, religious leaders, circumcisers, and even some medical personnel can contribute to upholding the practice.
§ In some societies, recent adoption of the practice is linked to copying the traditions of neighbouring groups. Sometimes it has started as part of a wider religious or traditional revival movement.
§ If she does not remove her clitoris, no man will marry her and she will be exiled from her tribe.
§ If she does not remove her clitoris, her children and family will die.
§ If she does not remove her clitoris, during childbirth, the clitoris will be pushed to the back of her skull and explode her skull.
§ The culture will die, and thus their people will die.
§ Their gods will be angered.
§ The will make too much noise (due to pleasure) during intercourse.
What could be the effects of this practice?
The medical complications endured by the women are both immediate and late. Immediate complications are defined as complications directly following the operation. Late complications are those appearing after the primary healing of the circumcision.
It was not difficult for most of the respondents to recall the suffering from the complications of female circumcision. Some gave detailed descriptions of the circumstances surrounding the act of circumcision and the immediate complications they experienced. However, a few of the respondents felt shy and were not able to speak of their genital organs. Therefore they probably underreported the complications that they had endured. This was especially relevant to the late complications, which included the symptoms the women were suffering from at the time of the interview. It was for instance difficult for them to admit, in the presence of strangers, that they were suffering of dribbling urine incontinence which is a common complication of infibulation.
COMMON COMPLICATIONS
Complications following FGM, especially if the girl is infibulated, are common and many are well documented. These may be immediate or late. The major immediate complications are, of course, hemorrhage from the dorsal artery, shock and then infection, urinary retention and tetanus, which can lead to mortality.10-12
Some late and long-term complications seen are urinary incontinence, cysts, urogenital tract infections, severe dyspareunia, pelvic inflammatory disease, infertility, and obstetrical problems such as delayed or obstructed second stage labor, trauma, and hemorrhage. Hemorrhage was also seen as a late complication especially in the newly married girl who was tightly infibulated and was subjected to forcible sex by the husband or who the husband defibulated using various instruments such as scissors, blades or knives.
In the research done by Dirie and Lindmark in Somalia on 290 women (mean age 22 years, range 18 to 54), 88% of research subjects had excision and infibulation, the remainder fell into the less mutilating categories. Sixty-nine percent had this procedure performed at home and 52% of these were performed by an untrained person. The immediate main complication reported by 112 women in the study was hemorrhage, infection, urinary retention, and septicemia (see Table 1). Five women reported severe shock and two of them required blood transfusions. Those women with urinary retention were treated by splitting the infibulation scar and were reinfibulated a few weeks later. The late complication of which 108 women complained, were as follows: 36 with clitoral cysts, 29 requiring excision; 57 with pain on micturition; and 15 subjects had poor urinary flow (see Table 2).
Hemorrhage is an immediate as well as a late complication. For hemostasis the girl's legs are tied together and sometimes a poultice of crushed medicinal herbs is applied.
The urinary retention reported by the women in the Dirie/Lindmark study occurred within the first 3 days after the operation and the reason given by the authors was that the girls tried to avoid passing urine because of the pain that urine causes when it irritates the raw surfaces. The retention was also due to skin flaps, blood clots or, in several cases the urinary meatus was sutured while closing the vulva.
Recurrent urinary tract infections and urinary problems were numerous, and according to Dirie/Lindmark, these were caused because the meatus was covered by the infibulation, causing vaginal discharge to accumulate and favor the growth of bacteria. The women reported that they were given antibiotics by their doctor and this helped. DeSilva reported that urinary tract infection with Escherichia coli was common in these women.
The most common late complication of FGM that was reported by Dirie and several other authors was vulvar swelling, which was due to epidermal cyst formation that develops along the scar tissue and in the excised clitoral region. Hanly13 discusses 10 patients that attended the hospital in Tabuk, Saudia Arabia. All patients were immigrants into the Kingdom from Africa. Six patients presented with a large painless mass in the infibulation scar. Two complained of pain, one gave a history of a white continuous secretion for the scar site, and one complained of severe dyspareunia and had a cyst measuning 5.5 X 5 X % cm. The pathological finding in eight patients was of an implantation dermoid, in the other two patients the cyst had ruptured.
Mayad discusses the fibrous connective tissue tumors called fibromata. These form in the same areas as the dermoid cysts and also can grow to be large and pedunculated.
SEXUALLY TRANSMITTED DISEASE,
PELVIC INFLAMMATORY DISEASE,
AND INFERTILITY
PELVIC INFLAMMATORY DISEASE,
AND INFERTILITY
Pelvic inflammatory disease (PID), a common complication of sexually transmitted disease (STD) is accompanied by abdominal pain, infertility, and ectopic pregnancy. Research indicates that PID is a major problem worldwide and in some African countries, 22 to 44% of women admitted to the hospital for gynecological problems had PID. In women 20-29 years old, 7 to 25% of them were childless.15 The most prevalent organisms were Neisseria gonnorrhoeae and Chlamydia trachomatis. However, it is now believed that FGM plays a significant role in the development of PID. For the woman who has been infibulated there are added risks of infection and resulting infertility. It has been reported by Sami and El Dareer3 that chronic pelvic disease was three times more prevalent in the infibulated women. Chronic retention of unire, menstrual flow, and repeated urinary tract infections with E. coliare the consequences of poor drainage, which results from a space fromed behind the vulva skin. This then becomes an excellent reservoir for the growth of pathogenic organisms such as the E. coli.
Shandall and DeSilva reported a high incidence of candiasis, which was more frequent with infibulation, and urine cultures showed the presence of mixed organisms, specifically E. coli. Shandall has suggested three main causes of PID in the infibulated woman, namely: (1) infection at the time of infibulation, (2) interference with drainage and (3) infection from spliting the infibulation and resulting resuture after labor. The infections then spread to the inner reproductive organs causing infertility.
Rushwan states that FGM should be recognized as an important etiological factor for PID. Another reason for infertility is acquired gynetresia which according to Ozumba, is directly related to infibulation. In a study done by Ozumba in Eastern Nigeria on 78 women (see Tables 3 and 4), 59 patients (76%) had acquired gynetresia caused by infibulation. Sexual intercourse is generally difficult and the process of deinfibulation painful and can take 2-12 weeks to complete or even up to 2 years during which time the women seeks medical help for infertility.
It is estimated that 2-25% of the cases of infertility in the Sudan are due to infibulation, either as a result of chronic pelvic infection or because of difficulty in having sexual intercourse and lack of penetration. In this society the psychological and social impact of being sterile must be profound because a woman's worth is frequently measured by her fertility, and being sterile can be cause for a divorce.
POSSIBLE HIV TRANSMISSION
It has been postulated that FGM may play a role in the transmission of HIV. One recent article which, was presented at the International Conference on AIDS 1998, was a study performed on 7350 young girls less than 16 years old in Dar es Salaam. In addition to other aspects of the research, it was revealed that 97% of the time, the same equipment could be used on 15-20 girls. The conclusion of the study was that the use of the same equipment facilitated HIV/AIDS/STD transmission.
At the same conference, a research study performed in Nairobi indicated that FGM predisposes women to HIV infection in many ways (e.g., increased need for blood transfusions due to hemorrhage either when the procedure is performed, at childbirth, or a result of vaginal tearing during defibulation and intercourse, and the use of the same instruments for other initiates). Because FGM raises the social status of the parents, the dowry demands can be high and therefore the young girls can be married off to older men who are already infected. Contact with blood during intercourse is believed to be responsible for the transmission of HIV infection among homosexuals.
Women who have had FGM done have a small opening, just large enough for the passage of urine and blood. Penetration or intercourse is difficult, often resulting in tissue damage, lesions, and postcoital bleeding. These tears would tend to make the squamous vaginal epithelium similar in permeability to the columnar mucosa of the rectum, thus facilitaing the possible transmission of HIV. The vaginal introitus is narrowed to increase the man's sexual enjoyment and ensure fidelity and virginity. However, because of the this many women experience severe dyspareunia. Other common reasons for the dyspareunia are epidermal or dermoid cysts, which form along the incisional site. These can be a small as a pea or as large as a football. These often become infected, painful, and a common reason for the woman seeking medical help. Dyspareunia can also be a result of neuromata that are formed when the dorsal nerve ending is trapped in scar tissue, resulting in immense pain and severe dyspareunia..
Unlike the rest of the world, sub-Saharan Africa has been more severely affected by HIV/AIDS. The sheer number of Africans infected is overwhelming. What is also of interest and concern is the number of women who are infected. The latest statistical data coming from WHO indicates that in Africa the ratio of male to female is 1:1, while in Europe and North America it is 4:1 (see Table 5). In Zimbabwe at 23 surveillance sites where the pregnant women were all tested anonymously for HIV, some 20-50% of them were found to be infected. At least one third of these women are likely to pass the infection on to their baby.
Linke points to the common factor of contact with blood during intercourse for transmission of HIV in homosexuals in the United States and heterosexuals in Africa. For many of the women with FGM who have been infibulated (pharaonic), vagina intercourse is difficult at best and is associated with repeated tissue damage and bleeding, subsequently anal intercourse is resorted to with heterosexual partners. Thus the proposition that HIV transmission is enhanced because of the widespread practice of FGM.
It is difficult for researchers to obtain accurate statistical data on anal intercourse for a host of reasons. Because of their cultural background, African women feel uncomfortable and shy discussing their sexual habits, and this is certainly true in the presence of males other than their husbands. Societal disapproval of anal intercourse is especially strong in areas where the majority of the population is Catholic, and admitting such behaviors can involve ostracization from the community. Moore et al., in a study done on 1480 students in Zaire, found that 19% stated that they practiced anal intercourse. Because the question of homosexuality and anal sex is considered taboo, many Africans, male and female, are unwilling to discuss or admit to these practices, so these are believed to be grossly underreported. There is a large body of convincing evidence that genital ulceration and other STDs increase susceptibility to HIV infection. In research done by Allen et al. on HIV infection in urban Rwanda, the association between dyspareunia and nonmenstrual bleeding are often seen as signs and symptoms of undiagnosed venereal disease. In fact, in almost all of the research, genital lesions and ulcerations are discussed in the context of STD. The European study did report that in women with a history of candidiasis, the rate of HIV infection was significantly higher. As stated earlier and by many authors, included in the complications of HIV infection was significantly higher. As stated earlier and by many authors, included in the complications of FGM are severe dyspareunia, postcoital bleeding, ulceration and a high incidence of candidiasis. There is no conclusive evidence on the linkage of FGM to HIV transmission. However, Post describes an incident from a letter sent by the Minority Rights Group to Ammnesty International as follows: "While in Malawi a couple of months ago, I came across the story of a 14 year-old girl of Yao tribe that inhabits land in the Southern end of the country. She was diagnosed as HIV-positive although she was a virgin. Blame was laid on the fact that during tribal circumcision, the same razor would be used on any number of children at the same time." Perhaps future research on HIV transmission should include, as a variable, women who have had FGM performed because they also have genital ulcers and abrasions. If there were conclusive evidence linking FGM with the transmission of HIV, this may then become the best weapon in the arsenal for eradication of this practice.
OBSTETRICAL COMPLICATIONS
There are many obstetrical complications associated with infibulation, for the mother and fetus/baby. However, Mawad and other authors stress that with careful planning, good antenatal, intrapartum and postpartum care, most of these can be avoided. Some of the main complications are delayed second-stage labor, perineal tearing, vesicovaginal fistula, and low birth weight babies. It has been reported that some pregnant women reduce their dietary intake to avoid giving birth to large babies. The obstetrical management for those patients is important and often difficult for those that have not had this type of exposure.
The Norwich Park Hospital in the United Kingdom has established an "African Well Woman Clinic" with a specially trained staff and protocols in place for the management of the FGM women. The necessity for this arose because of the high influx of immigrants from the Sudan and Somalia. These areas in Africa are where infibulation is practiced on at least 95% of the women. On staff there is a female Somali translator and a Sudanese psychologist. Since the clinic's inception the number of persons visiting the clinic has risen from under 1% to almost 6%. In the research done by McCaffery on 50 of the patients that attended the clinic, 13 were nonpregnant, 14 were primigravida, and 23 multigravida. The main reason for the nonpregnant women's attendance was to request defibulation. At first visit the average gestational age was 15-20 weeks. Of the 14 primigravida patients, 7 had an adequate introitus to facilitate first- and second-stage labor. One patient had a deinfibulation done earlier, two requested antenatal deinfibulation and three preferred the procedure to be done at the time of delivery (one patient did not return to the clinic). Thirteen (93%) primigravida patients had vaginal deliveries, and all of these had either episiootomies or perineal lacerations. Fourteen (61%) multiparous had vaginal deliveries. Six (25.1%) had caesarean sections, and with three (13%) instrumentation was used. Included in this research is an excellent in-depth discussion of the problems encountered and the obstetrical management Two cases are discussed in detail. The first was a 26-year-old Sudanese (primigravida) presented at 26 weeks gestation with severe vulval itching. The introital opening measured less than 1 cm, so a speculum exam was not possible. A swab was passed and cultured Candida albicans. However, the insertion of the applicator for clotrimazole cream was not possible. Because of the severity of her symptoms, the woman underwent defibulation at 28 weeks' gestation and subsequently had a normal vaginal delivery.
For the infibulated mother in labor with a narrow introitus, the inability to do a vaginal exam to monitor progress, apply fetal scalp electrodes, or blood sampling are for the obstetrician mid-wife serous reasons for concern. The second case discussed was that of a 20-year-old Somali primigravida admitted with contractions at full term. The introitus barely admitted one finger and cardiotocography of the fetal heart showed 60 bpm without a contraction. An epidural anesthesia was administered to facilitate vaginal exam, and at this time the cervix was 2 cm dilated. Artificial rupture of the membrane was performed and revealed thick black meconium. The decision was made to perform a cesarean section. However a catherization could not be done, so deinfibulation was carried out to facilitate this. The author while in Saudia Arabia in 1980, found that a urethral catherization on the infibulated woman was quite difficult and unsuccessful at times due to extensive scar tissue, bands, and anatomical distortion. Valuable time can be lost in an emergency. The staff at the African Well Woman Clinic have developed a high level of expertise in caring for the infibulated woman, and from research it is evident that they have incorporated all aspects of well-being including psychological and cultural. The staff strongly recommends antenatal defibulation or elective reversal either before pregnancy, at 20 weeks gestation or if seen later in pregnancy than at 38 weeks. It takes about 1 week for the reversal to heal. This procedure should be performed under spinal anesthesia because the sensation of touch triggers flashbacks of the infibulation in childhood. In the nonpregnant women, general anesthesia is recommended.
LEGAL RAMIFICATIONS
Many countries such as Canada, England, Sweden, Australia, and others have enacted statutes prohibiting FGM and reinfibulation after delivery. In the United States a law was passed in 1997 which criminalizes FGM performed on a person who has not reached the age of 18 years but it does not address women older than 18 or reinfibulation after delivery. Infibulation was made illegal in Sudan in 1946 and still today nearly 90% of the women in Sudan have been subjected to FGM. Because FGM is now illegal, many young girls are taken out of the country to have it performed. The Center for Disease Control and Prevention estimates that there are over 150,000 females at risk in the United States for undergoing FGM. Clearly it will take more than legislation to eradicate this practice that can no longer be seen as a religious or traditional custom. One cannot mount an ethical defense for a practice that results in such a negative impact on a woman's health. This is not only a problem for countries where it is performed, but also for the Western Countries.
Health-care providers have an important role to fulfill in the eradication of this practice. We should act as advocates and increase professional and public awareness about such a practice, explaining the dangers and life-long disabilities it imposes. Perhaps the well-known crusader for eradication of FGM, who herself had this done, Merserak (Mimi) Ramsey, spoke for all women when she said, "This is a pain that doesn't go away. It is a lifetime wound,"
How do the women who had undergone FGM felt?
No one could ever answer this question more than the person who has experienced the process firsthand. This is an excerpt of an interview of an African girl who underwent the procedure. Her name Lucy Mashua, the Global Ambassador for fighting FGM (Female Genital Mutilation)
Lucy:
I was born 30 years ago in a small village in southern Kenya in Rift valley province. I come from the Maasai tribe, which is known for its cultural wearing of beads, red ochre and wraps. We are nomadic people and move with our animals from one place to another in search of pastures, as it’s a semi arid area. We have three major groups in Africa: Bantu, Cushites and Nilots.
My tribe falls into the Nilots group and the tribe from which Obama’s father comes from, Luo. We migrated from Egypt in 16 AD, named after the river Nile and most of us are black Jews, but practicing Christianity. I am a Christian.
I love my tribe so much that I want them to treat women and children right by ending FGM and early child marriage. Women and girls are not men’s properties. It is our God- given right not to be mutilated and married off at a tender age. I am the first born of a family of six and underwent FGM at the age of 9 one early morning with a group of other girls. Vaginal genocide was committed on us.
And now here I am living to tell and be a voice for the voiceless.
My tribe practices FGM because they are ignorant and brainwashed since the days of Pharaoh in Egypt as they migrated to East Africa with this tradition. The philosophy is that women will be more tame and controllable. When a woman is made to feel like she is an object and not 100% human, she will fall for it. They become puppets and not valued, but it didn’t work with me.
They also engage in early childhood marriage to control and tame women because if you are married off at 12, by the time you are 18 you are just worn out and you will never see the need to explore life. The younger the girls are, the easier it is to control and manipulate them. It’s also about wealth. The more wives and cattle you have, the wealthier you are and you have more property.
One chilly morning in a group of 29 girls, we were mutilated. I was tied with a rope because I was screaming and begging them to stop. Some girls were considered brave for not crying aloud. But I know their heart cried out loud. I could hear their cry and still do.
It is so hard for me to talk about this. It’s so fresh. I am still so traumatized. They used the same knife on us, not caring about any infections. These are tradition mutilators and midwives that perform this savagery. My mom could not watch this. Up to now, I am scared of any human blood. I scream when I accidentally cut myself. A few days ago I passed out when I cut my finger and I hurt my back as I live by myself. No one could help me.
I have nightmares. I have never coped. I have very painful PMS. I have extra glands growing so I need surgery. I have scar tissues. That’s why my vagina muscles hurt. I will live with this for the rest of my life. I will never cope but one thing for sure I will never stop voicing out against FGM.
One day I will reach the World Court and criminalize globally FGM. I swear I am going to reach there. I am now building a very big network of very committed people. I aspire even to be a human rights movie documentary producer. I am going to get words out there and catch the attention of all kinds of good people. I will kick FGM ass out of this planet. And that makes me smile.
First I was rejected by my own society, relatives and friends because of my strong uncompromised belief that women are human too and that no one should take a razor, knife or sharp glass to cut off our clitoris.
No man owns a woman and no one has the right to beat or hit a woman. I have watched my mom suffer at the hands of men and I had enough and began my rebellion by not obeying what men wanted from me and I knew then I have begun a war.
As young as 6 years old I would open my mouth and shout to the top of my voice in a gathering to speak my mind out. Of course I would get beatings but I grew immune. I could not cry anymore from the beatings but I cry out when my friends and relatives undergo FGM.
My fight against FGM has landed me in jail as a protester. I have suffered beatings, rejection, sexual abuse, separation from my babies. I have been tortured physically, sexually and emotionally. I have physical scars all over my body. Up to this time there are times my mind goes back and it’s like a horror movie. I suffered a great deal but I thank God almighty for America.
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