Female Genital Mutilation

 

Alternative Names: Female genital cutting (FGC), female circumcision, or female genital mutilation/cutting (FGM/C)

Definition:
Female Genital Mutilation is defined by the World Health Organisation as “all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons”[neutrality is disputed] The term is exclusively used to describe traditional or religious procedures on a minor, which requires the parents’ consent because of the age of the girl.

When the procedure is performed on and with the consent of an adult, it is generally called clitoridectomy, or it may be part of labiaplasty or vaginoplasty. It also generally does not refer to procedures used in sex reassignment surgery, and the genital modification of intersexuals.

It’s one of the most political areas of women’s health. Worldwide it’s estimated that well over 120 million women have been subjected to it. Supporters of the practice say it’s an important part of cultural and religious life, and some compare it to the practice of male circumcision that is more widely accepted in the Western world, but opponents say that not only is it potentially life-threatening – it’s also an extreme form of oppression of women.

In some countries where it’s more widely practised it’s officially illegal – those who persist in the practice in Senegal will now face a prison term of between one and five years, for example. But it’s still carried out quietly, within the family and out of sight of officials.

Female Genital Mutilation is predominantly practiced in Northeast Africa and parts of the Near East and Southeast Asia,It’s also known to take place among immigrant communities in the USA, Canada, France, Australia and Britain, where it’s illegal. In total it’s estimated that as many as two million girls a year are subjected to genital mutilation.

Opposition is motivated by concerns regarding the consent (or lack thereof, in most cases) of the patient, and subsequently the safety and long-term consequences of the procedures. In the past several decades, there have been many concerted efforts by the World Health Organization (WHO) to end the practice of FGM/C. The United Nations has also declared February 6 as “International Day of Zero Tolerance to Female Genital Mutilation“.

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  (you may seethe  Diagram ), 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

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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.

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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.[28] 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 menstrual 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.

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, 2007, p. 2).

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.”

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

Reasons for female genital mutilation:
The reasons for female genital mutilation include a mix of cultural, religious and social factors within families and communities.

*Many communities may not even question the practice or may have long forgotten the reasons for it. Others, however, assertively justify the practice. For example, mothers who have their daughters circumcised believe they are doing the right thing-because their children would become social outcasts if they did not get circumcised. Another less common reason given for infibulation or excision is decreasing a woman’s sexual desire in order to preserve virginity. Infibulation is intended to dull women’s sexual enjoyment, and it appears to be extremely effective.

*Where FGM is a social convention, the social pressure to conform to what others do and have been doing is a strong motivation to perpetuate the practice.

*FGM is often considered a necessary part of raising a girl properly, and a way to prepare her for adulthood and marriage.

*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”.
*Various works of fiqh (Islamic jurisprudence) support the removal of the female prepuce. For example, the fourteenth-    century text ‘Umdat al-Salik wa-‘Uddat al-Nasik, translated as The Reliance of the Traveller, writes, “Circumcision is obligatory (O: for both men and women). For men it consists of removing the prepuce from the penis, and for women, removing the prepuce (Ar. bazr) of the clitoris (n: not the clitoris itself, as some mistakenly assert). (A: Hanbalis hold that circumcision of women is not obligatory but sunna, while Hanafis consider it a mere courtesy to the husband.)”

*[Muslim 003,0684] […] Abu Masa then said, “When is a bath obligatory?” Aisha responded, “You have asked the right person. Mohammed has said that a bath is obligatory when a man is encompassed by a woman and their circumcised genitalia touch.”

*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 most societies, FGM is considered a cultural tradition, which is often used as an argument for its continuation.

*In some societies, recent adoption of the practice is linked to copying the traditions of neighboring groups. Sometimes it has started as part of a wider religious or traditional revival movement.

*In some societies, FGM is being practiced by new groups when they move into areas where the local population practice FGM

Cultural & Religious Aspects:
A Greek papyrus from 163 B.C. mentions both boys and girls in Egypt undergoing circumcision and it is widely accepted to have originated in Egypt and the Nile valley at the time of the Pharaohs. Evidence from mummies has shown both Type I and Type III FGC present.

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Al-Azhar Supreme Council of Islamic Research, the highest religious authority in Egypt, issued a statement saying FGM/C has no basis in core Islamic law or any of its partial provisions and that it is harmful and should not be practiced.”

Coptic Pope Shenouda, the leader of Egypt’s minority Christian community, said that neither the Qur’an nor the Bible demand or mention female circumcision.

Medical Consiquence:
Among practising cultures, FGC is most commonly performed between the ages of four and eight, but can take place at any age from infancy to adolescence. Prohibition has led to FGC going underground, at times with people who have had no medical training performing the cutting without anesthetic, sterilization, or the use of proper medical instruments. The procedure can lead to death through shock from excessive bleeding. The failure to use sterile medical instruments may lead to infections.

Other serious long term health effects are also common. These include urinary and reproductive tract infections, caused by obstructed flow of urine and menstrual blood, various forms of scarring and infertility. Epidermal inclusion cysts may form and expand, particularly in procedures affecting the clitoris. These cysts can grow over time and can become infected, requiring medical attention such as drainage.[39] The first episode of sexual intercourse will often be extremely painful for infibulated women, who will need the labia majora to be opened, to allow their partner access to the vagina. This second cut, sometimes performed by the partner with a knife, can cause other complications to arise.

A June 2006 study by the WHO has cast doubt on the safety of genital cutting of any kind.   This study was conducted on a cohort of 28,393 women attending delivery wards at 28 obstetric centers in areas of Burkina Faso, Ghana, Kenya, Senegal and The Sudan. A high proportion of these mothers had undergone FGC. According to the WHO criteria, all types of FGC were found to pose an increased risk of death to the baby (15% for Type I, 32% for Type II, and 55% for Type III). Mothers with FGC Type III were also found to be 30% more at risk for cesarean sections and had a 70% increase in postpartum hemorrhage compared to women without FGC. Estimating from these results, and doing a rough population estimate of mothers in Africa with FGC, an additional 10 to 20 per thousand babies in Africa die during delivery as a result of the mothers having undergone genital cutting.

In cases of repairing the damage resulting from FGC, called de-infibulation when reversing Type III FGC, this is usually carried out by a gynecologist. See also Pierre Foldes, a French surgeon, who developed modern surgical corrective techniques.

HIV:
Relatively little research has been conducted on the effect female genital alteration may have on HIV prevalence.  Some studies have found increased risk of HIV among women who had undergone FGC. Other studies have found no statistically significant associations, or have identified more complex patterns. Two studies have reported that FGC is associated with decreased risk of HIV.

Kanki et al. (1992) reported that, in Senegalese prostitutes, women who had undergone FGC had a significantly decreased risk of HIV-2 infection when compared to those who had not.  Klouman et al. (2005), studying women in Tanzania, found that among women who had undergone FGC the odds of being HIV positive were roughly twice those among women who had not. However, both HIV and FGC were strongly associated with age; when controlling for age, the association was no longer statistically significant.

Brewer et al. (2007) found that in virgins, FGC was associated with a higher prevalence of HIV infection (3.2% vs 1.4%), which the authors attributed to non-sterile procedures. Among sexually experienced women, FGC was associated with lower HIV prevalence (5.5% vs 9.9%). The authors suggested two possible reasons: that an HIV-specific immunity might be acquired through FGC procedures, and mortality of those infected at the time of FGC would reduce HIV prevalence in surviving adults.  Maslovskaya et al. (2009) found that FGC was associated with higher risk of HIV among women whose first-union partner was younger or the same-age, but it was associated with lower risk of HIV among women whose first-union partner was older than the women herself.  Yount et al. reported that, although FGC and HIV were not directly related, FGC was indirectly related to HIV via a number of associations with other factors, including extra-union partners, early onset of sexual activity, being widowed or divorced, and having an older partner. The authors concluded that FGC “may be an early life-course event that indirectly alters women’s odds of becoming infected with HIV through protective and harmful practices in adulthood”.

Recent reviews have suggested that FGC may increase the risk of HIV.  Several mechanisms have been proposed by which FGC would expose women to greater risk of HIV. These include: non-sterile procedures (Monjok notes that the same instrument is frequently used on 15–20 girls); an increase in blood transfusions due to blood loss during the procedure itself, intercourse, or childbirth; increased anal intercourse due to difficult or painful vaginal intercourse; tearing of the vagina during intercourse;   and increased susceptibility to infectious conditions that are recognised risk factors for HIV, such as genital ulcers

Sexual Effects:
The effect of FGC on a woman’s sexual experience varies depending on many factors. FGC does not eliminate all sexual pleasure for all women who undergo the procedure, but it does reduce the likelihood of orgasm. Stimulation of the clitoris is not solely responsible for the sexual excitement and arousal of a woman during intercourse; this involves a complex series of nerve endings being activated and stimulated in and around her vagina, vulva (labia minora and majora), cervix, uterus and clitoris, with psychological response and mindset also playing a role.

Lightfoot-Klein (1989) studied circumcised and infibulated females in Sudan, stating, “Contrary to expectations, nearly 90% of all women interviewed said that they experienced orgasm (climax) or had at various periods of their marriage experienced it. Frequency ranged from always to rarely.” Lightfoot-Klein stated that the quality of orgasm varied from intense and prolonged, to weak or difficult to achieve.

A study in 2006 found that in some infibulated women, some erectile tissue fundamental to producing pleasure had not been completely excised. Defibulation of subjects revealed that a part of or the whole of the clitoris was underneath the scar of infibulation. The study found that sexual pleasure and orgasm are still possible after infibulation, and that they rely heavily on cultural influences — when mutilation is lived as a positive experience, orgasm is more likely. When FGC is experienced as traumatic, its frequency drops. The study suggested that FGC women who did not suffer from long-term health consequences and are in a good and fulfilling relationship may enjoy sex, and women who suffered from sexual dysfunction as a result of FGC have a right to sex therapy.

Psychological and Psychiatric Consequences:
In February 2010, a study by Pharos, a Dutch group which gathers information on health care for refugees and migrants, found that many women who have undergone FGC suffer psychiatric problems. This was the first study into the psychiatric and social complaints associated with female circumcision. In the study 66 questioned Dutch African women, who had been subjected to the practice, were found to be “stressed, anxious and aggressive”. It also found that they were more likely to have relational problems or in some cases had fears of establishing a relationship. According to the study, an estimated 50 women or girls are believed to be circumcised every year in the Netherlands. The report was published to mark the International day against female genital mutilation.

A study by anthropologist Rogaia M. Abusharaf, found that “circumcision is seen as ‘the machinery which liberates the female body from its masculine properties’  and for the women she interviewed, it is a source of empowerment and strength”.

Latest Psychological effects, sexual function:
According to a 2015 systematic review there is little high-quality information available on the psychological effects of FGM. Several small studies have concluded that women with FGM suffer from anxiety, depression and post-traumatic stress disorder. Feelings of shame and betrayal can develop when women leave the culture that practises FGM and learn that their condition is not the norm, but within the practising culture they may view their FGM with pride, because for them it signifies beauty, respect for tradition, chastity and hygiene.[10]

Studies on sexual function have also been small. A 2013 meta-analysis of 15 studies involving 12,671 women from seven countries concluded that women with FGM were twice as likely to report no sexual desire and 52 percent more likely to report dyspareunia (painful sexual intercourse). One third reported reduced sexual feelings.

Reversal:
In recent years, surgical techniques to reverse FGM have been developed by gynecologists such as Dr. Pierre Foldes and Dr. Marci Bowers. Techniques can include ablating scar tissue, reconstructing the labia, and drawing the internal part of the clitoris outward to compensate for clitoral excision.

FGC can now be partially reversed via a surgical technique, which gives back certain sensation to the genitalia. Clitoraid, a non-profit international organization, is in the process of building a hospital in Burkina Faso, West Africa, where women who have undergone FGC will be able to receive this procedure free of charge. The hospital will be staffed with volunteers, including surgeons who specialise in the technique

What is the future?
Due to health campaigns, female circumcision has been falling in some countries in the last decade. Several international organisations such as the World Health Organisation and the United Nations are actively working to stop the practice, and an increasing number of countries have outlawed it.

In Kenya, a 1991 survey found that 78 per cent of teenagers had been circumcised, compared to 100 per cent of women over 50. In Sudan, the practice dropped by 10 per cent between 1981 and 1990.

Several governments have introduced legislation to ensure the process is only carried out in hospitals by trained doctors.

Other countries such as Egypt have banned the operation altogether, but there is significant opposition to change because of the traditional nature of the process. Health workers think a less confrontational approach such as Ntanira Na Mugambo, which combines education with an understanding of the thinking behind female genital mutilation, could be more successful.

Ntanira Na Mugambo, also known as ‘circumcision by words’, has been developed in rural areas of Kenya by local and international women’s health organisations.

It involves a week-long programme of community education about the negative effects of female genital mutilation, culminating in a coming of age ceremony for young women.

The young women are secluded for a week and undergo classes in:

•Reproduction
•Anatomy
•Hygiene
•Respect for adults
•Developing self-esteem
•Dealing with peer pressure
Family members also undergo health education sessions and men in the community are taught about the negative effects of female circumcision.

Health workers believe the programme works because it does not exert a blunt prohibition on female genital mutilation, but offers an attractive alternative.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
http://en.wikipedia.org/wiki/Female_genital_cutting
http://www.bbc.co.uk/health/physical_health/conditions/female_genital_mutilation.shtml

Female circumcision is common


http://rashmanly.wordpress.com/2009/10/14/female-genital-mutilation-shocking-wicked-evil/

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