Female Genital Mutilation (FGM)
Introduction
Female genital mutilation involves partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons. In the name of cultural tradition millions of women and girls are genitally mutilated. The United Nations Children’s Fund estimates each year about three million women and girls are subjected to FGM, predominantly in parts of Africa and a few countries in Asia and the Middle East. Women who have had FGM are also seen in immigrant communities in Australia, Canada, Europe, New Zealand and the USA. The practice violates the basic human rights of girls’ and women, denying them their physical and mental integrity, their right to freedom from violence and discrimination and, in the most extreme cases their life. FGM is an issue for all nurses, as girls and women who have undergone the procedure are likely to suffer significant physical, mental and psychological problems; and it is important for nurses to understand the socio-cultural justifications behind FGM in order to provide the best care possible.
What is Female Genital Mutilation (FGM)?
Female genital mutilation (FGM), also known as female circumcision or female genital cutting, is defined by the World Health Organization (WHO) as the range of procedures which involve "the partial or complete removal of the external female genitalia or other injury to the female genital organs whether for cultural or any other non-therapeutic reason".
It is estimated that approximately 138 million African women have undergone FGM worldwide and each year, a further 2 million girls are estimated to be at risk of the practice. Most of them live in African countries, a few in the Middle East and Asian countries, and increasingly in Europe, Australia, New Zealand, the United States of America and Canada.
The procedure is traditionally carried out by an older woman with no medical training. Anesthetics and antiseptic treatment are not generally used and the practice is usually carried out using basic tools such as knives, scissors, scalpels, pieces of glass and razor blades. Often iodine or a mixture of herbs is placed on the wound to tighten the vagina and stop the bleeding.
The age at which the practice is carried out varies, from shortly after birth to the labor of the first child, depending on the community or individual family. The most common age is between four and ten, although it appears to be falling. This suggests that circumcision is becoming less strongly linked to puberty rites and initiation into adulthood.
Classification of FGM:
The World Health Organization (WHO) provides four different categories of female genital mutilation:
• Type I – excision of the prepuce, with or without excision of part or all of the clitoris
• Type II – excision of the clitoris with partial or total excision of the labia minora
• Type III “Infibulations” – excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening
• Type IV – recent classification to include any of the alternative rituals, which range from pricking, piercing or incising of the clitoris and/or labia; stretching of the clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue; scraping of tissue surrounding the vaginal orifice or cutting of the vagina.
The most common type of female genital mutilation is excision of the clitoris and the labia minora, accounting for up to 80% of all cases; the most extreme form, infibulation, only constitutes about 15% of all procedures.
Prevalence:
Female genital mutilation is still most often found in 28 countries of Africa along with some countries in the Middle East and Asia. However, with globalization and growing migration, FGM is now practiced in countries where it was not traditionally found, in immigrant populations in Australia, Canada, Europe, New Zealand and the United States of America. The type of FGM practiced varies by country and even by community.
Why FGM Exists:
In societies that practice FGM, it is considered to be a rite of passage to mark the transition from childhood to womanhood. Used as a way to control women’s sexuality, however, FGM is a manifestation of gender inequality and discrimination related to the historical suppression and subjugation of women, denying girls and women the full enjoyment of their rights and liberties. A number of rationalizations attempt to justify and perpetuate FGM as integral part of cultures:
• Sociological reasons: initiation of girls into womanhood, social integration, establishment a woman’s eligibility for marriage, and ingrained notions that parents must cut their daughters in order to be good parents. In some societies, girls who remain uncut are considered unmarriageable.
• Psychosexual reasons: reduce the sexual thoughts and desires of women, maintain chastity and virginity before marriage and fidelity during marriage, bring greater sexual pleasure to husbands.
• Hygienic/Aesthetic reasons: external female genitalia are considered dirty and unsightly and are to be removed to promote hygiene and provide aesthetic appeal.
• Religious/Mythical reasons: enhance fertility, make childbirth easier, and although no religion condones FGM, many communities believe it to be a requirement of their religion.
FGM as a Human Rights Violation:
Genital mutilation infringes on the rights of women and girls to reproductive health and bodily integrity and subjects them to torturous and degrading practices. It is a manifestation of gender-based human rights violations that exist in cultures that aim to control women's sexuality and autonomy. The rights to physical and mental integrity, to freedom from discrimination and to the highest standard of health are universal, and cultural claims cannot be invoked to justify their violation.
Subjecting girls and women to female genital mutilation without their consent violates a number of recognized regional and international human rights instruments. The Convention on the Rights of Child, the Convention on the Elimination of all forms of Discrimination Against Women, and many other human rights agreements, explicitly recognize the harm this practice can inflict on girls and young women. In fact, in 2003 the African Union issued the Protocol on the Rights of Women in Africa, calling for the elimination of discrimination against women in law, policies, development plans, and all spheres of life, including eliminating harmful cultural and traditional practice, explicitly mentioning the practice of Female Genital Mutilation.
Where is FGM Practiced?
The majority of cases of FGM are carried out in 28 African countries. In some countries, (e.g. Egypt, Ethiopia, Somalia and Sudan), prevalence rates can be as high as 98 per cent. In other countries, such as Nigeria, Kenya, Togo and Senegal, the prevalence rates vary between 20 and 50 per cent. It is more accurate however, to view FGM as being practiced by specific ethnic groups, rather than by a whole country, as communities practicing FGM straddle national boundaries. FGM takes place in parts of the Middle East, i.e. in Yemen, Oman, Iraqi Kurdistan, amongst some Bedouin women in Israel, and was also practiced by the Ethiopian Jews, and it is unclear whether they continue with the practice now that they are settled in Israel. FGM is also practiced among Bohra Muslim populations in parts of India and Pakistan, and amongst Muslim populations in Malaysia and Indonesia.
As a result of immigration and refugee movements, FGM is now being practiced by ethnic minority populations in other parts of the world, such as USA, Canada, Europe, Australia and New Zealand. FORWARD estimates that as many as 6,500 girls are at risk of FGM within the UK every year.
Consequences of FGM:Depending on the degree of mutilation, FGM can have a number of short-term health implications:
1. severe pain and shock
2. infection
3. urine retention
4. injury to adjacent tissues
5. immediate fatal haemorrhaging
Long-term implications can entail:
1. extensive damage of the external reproductive system
2. uterus, vaginal and pelvic infections
3. cysts and neuromas
4. increased risk of Vesico Vaginal Fistula
5. complications in pregnancy and child birth
6. psychological damage
7. sexual dysfunction
8. difficulties in menstruation
In addition to these health consequences there are considerable psycho-sexual, psychological and social consequences of FGM.
Justifications of FGM:
The roots of FGM are complex and numerous; indeed, it has not been exactly possible to determine when or where the tradition of FGM originated.
The justifications given for the practice are multiple and reflect the ideological and historical situation of the societies in which it has developed. Reasons cited generally relate to tradition, power inequalities and the ensuing compliance of women to the dictates of their communities
Reasons include:
1. custom and tradition
2. religion; in the mistaken belief that it is a religious requirement
3. preservation of virginity/chastity
4. social acceptance, especially for marriage
5. hygiene and cleanliness
6. increasing sexual pleasure for the male
7. family honour
8. a sense of belonging to the group and conversely the fear of social exclusion
9. enhancing fertility
Many women believe that FGM is necessary to ensure acceptance by their community; they are unaware that FGM is not practiced in most of the world.
Where does FGM take place?
The majority of cases of FGM are carried out in 28 African countries. In some countries, (e.g. Egypt, Ethiopia, Somalia and Sudan), prevalence rates can be as high as 98 per cent.
In other countries, such as Nigeria, Kenya, Togo and Senegal, the prevalence rates vary between 20 and 50 per cent. It is more accurate however, to view FGM as being practised by specific ethnic groups, rather than by a whole country, as communities practising FGM straddle national boundaries. FGM takes place in parts of the Arabian Peninsula, i.e. Yemen and Oman, and is practised by the Ethiopian Jewish Falashas, some of whom have
recently settled in Israel. It is also reported that FGM is practised among Muslim populations in parts of Malaysia, Pakistan, Indonesia, and the Philippines.
As a result of immigration and refugee movements, FGM is now being practised by ethnic minority populations in other parts of the world, such as USA, Canada, Europe, Australia and New Zealand. FORWARD estimates that as many as 6,500 girls are at risk of FGM within the UK every year.
Origin of FGM:
It is not entirely clear where or when the practice of FGM originated, although, there is some evidence suggesting that it originated in Ancient Egypt. An alternative explanation is that the practice was an old African rite that came to Egypt by diffusion. The most severe form of FGM – infibulation - was carried out in northern and central Sudan, Somalia, and Djibouti, where Arab and Black African cultures met. It is reported that infibulation was enforced on Black African women in the ancient Arab slave trade.2 It has also been suggested that the practice originated in the deserts of north-east Africa, and was then transmitted between regions during phases when FGM practicing populations made military conquests over non practicing groups. It is possible that FGM was introduced when the Nile valley was invaded by militant pastoral nomads around 3100 BC.3 Later, FGM may have developed independently among certain ethnic groups in sub-Saharan Africa as a rite of passage into womanhood.
FGC around the World:
Type I, II and III female genital mutilation have been documented in 28 countries in Africa, and in a few countries in Asia and the Middle East. Growing migration has increased the number of girls and women living outside their country of origin who have undergone female genital mutilation or who may be at risk of being subjected to the practice.
|
COUNTRY |
PREVALENCE (%) |
TYPE PERFORMED |
|
Benin |
16.8 |
II |
|
Burkina Faso |
76.6 |
II – Performed throughout the country in all but a few provinces. |
|
Cameroon |
1 |
I, II |
|
Central African Republic |
35.9 |
I, II |
|
Chad |
44.9 |
II – Widely practiced in all parts of Chad.
III – Confined to areas bordering Sudan in the eastern part of the country. |
|
Cote d’Ivoire
(Ivory Coast) |
44.5 |
II |
|
Djibouti |
90-98 |
II – Performed on girls of Yemeni origin.
III – Most common among the Issa and Afar. |
|
DRC (Congo) |
Unknown |
II |
|
Egypt |
97.3% |
I, II, III |
|
Eritrea |
88.7 |
I, II, III |
|
Ethiopia |
79.9 |
I – Commonly practiced among Amharas, Tigrayans and the Jeberti Muslims living in Tigray.
II – Most commonly practiced form. The Gurages, some Tigrayans, Oromos and the Shankilas practice this form.
III – Practiced in the eastern Muslim regions bordering Sudan and Somalia.
IV – Referred to as “Mariam Girz” in Ethiopia, it is practiced mainly in Gojam in the Amhara region. |
|
Gambia |
60-90 |
I – The Sarahulis perform this on girls one week after birth. The Bambaras perform the procedure on girls between 10-15 years of age.
II – Nearly all Mandinkas, Jolas and Hausas practice this form on girls 10-15 years old.
III – The Fulas perform a procedure similar to Type III that is described as “vaginal sealing” on girls from one week old to 18 years old.
IV – The Fulas perform this type on girls from one week old to 18 years old. |
|
Ghana |
5.4 |
I, II, III |
|
Guinea |
98.6 |
I, II, III, IV |
|
Indonesia |
100 |
I, IV |
|
Kenya |
32.2 |
I and II most common.
III – found in the far eastern areas bordering Somalia. |
|
Liberia |
50 |
II |
|
Mali |
91.6 |
I, II, III
(Type III practiced in southern areas of country) |
|
Mauritania |
71.5 |
I, II |
|
Niger |
4.5 |
II |
|
Nigeria |
19 |
I, II, III, IV
(Type I and II more prominent in the south; Type III more prominent in north) |
|
Senegal |
28.2 |
II, III
(Type II is most common) |
|
Sierra Leone |
80-90 |
II |
|
Somalia |
90-98 |
I – practiced mainly in the coastal towns of Mogadishu, Brava, Merca, and Kismayu.
III – Approximately 80% of the circumcisions are this type. |
|
Sudan |
90 |
I, II, III
(Type III is most common) |
|
Tanzania |
17.7 |
II, III |
|
Togo |
12 |
II |
|
Uganda |
5 |
No information available. |
|
Yemen |
22.6 |
II, III |
Africa: the FGM record:
The table in the file here attached (Estimates by country) is taken from 2 Million Girls A Year Mutilated, The Progress of Nations 2000, Women, UNICEF. The table shows the countries, estimates of the number of women who suffer genital mutilation, and data regarding country policies.
Between 100 and 140 million girls and women in the world are estimated to have undergone such procedures, and 3 million girls are estimated to be at risk of undergoing female genital mutilation every year. Female genital mutilation has been documented in 28 countries in Africa and in several countries in Asia and the Middle East. Some forms of the practice have also been reported from other countries, including among certain ethnic groups in Central and South America. There is also evidence of increasing numbers of girls and women living outside their place of origin, including in North America and western Europe, who have undergone or may be at risk of undergoing female genital mutilation.
Extensive work by local, national and international actors over the past two to three decades has resulted in progress on several fronts. The practice is internationally recognized as a violation of human rights, and many countries have put in place policies and legislation to ban it. The number of women from practising areas who do not want to continue the practice is increasing, and there are indications that the prevalence is declining in some countries, and that it is less prevalent in younger than in older age groups. Despite these successes however, the overall decline has been very slow. Hence, to accelerate the process of abandonment of the practice, there is an urgent need for increased and improved work by all actors, since there is evidence now that we know what is necessary to stimulate large-scale and speedy abandonment. Some highly successful projects, increased knowledge about the practice itself and the reasons for its continuation as well as experiences with a vast variety of interventions, some of which have proven very successful, suggest that it will be possible to significantly reduce the prevalence within one generation. This, combined with advocacy at the international level, has created a momentum suggesting that such a change is possible, and that the willingness to invest the necessary resources can be achieved.
WHO is working on several fronts to contribute to the elimination of female genital mutilation. International and national advocacy is important. Together with ten other UN agencies WHO has developed a new Interagency Statement on Eliminatingg Female Genital Mutilation that will be launched in early 2008.
The type of procedure performed also varies, mainly with ethnicity. Current estimates indicate that around 90% of female genital mutilation cases include Types I or II and cases where girls' genitals were 'nicked' but no flesh removed (Type IV), and about 10% are Type III.
The procedure is generally carried out on girls under the age of 15 years, although obtaining data on female genital mutilation prevalence in that age group poses several methodological challenges, not least of which is ascertaining if and how the procedure was carried out. Recent surveys have found that, in Egypt, 90% of girls who had undergone female genital mutilation were between five and 14 years of age when subjected to the procedure, 50% of those in Ethiopia, Mali and Mauritania were under five years of age, and 76% of those in the Yemen were not more than two weeks old. In some communities, women who are about to be married or are pregnant with their first child or who have just given birth also undergo the practice.
Prevalence and age:
WHO estimates that between 100 million and 140 million girls and women worldwide have been subjected to one of the first three types of female genital mutilation. Estimates based on the most recent prevalence data indicate that 91.5 million girls and women above 9 years old in Africa are currently living with the consequences of female genital mutilation. There are an estimated 3 million girls in Africa at risk of undergoing female genital mutilation every year.
Estimates on prevalence of female genital mutilation come from large-scale, national surveys, which have so far been conducted in 18 African countries, asking women aged 15-49 years if they have themselves undergone the practice. The prevalence varies considerably, both between and within regions and countries, with ethnicity as the most decisive factor. In seven countries the national prevalence is almost universal (more than 85%); four countries have high prevalence (60 to 85%); medium prevalence (30 to 40%) is found in seven countries; and low prevalence (0.6 to 28.2%) is found in nine countries. There is often marked variation in prevalence in different parts of any given country.
FGM prevalence among women aged 15-49:
Trends:
Although prevalence data obtained over the last decade have shown little change in the frequency of FGM, they do reveal several trends. Possibly as a result of an emphasis on the negative health implications of FGM, there has been a dramatic increase in the proportion of FGM operations carried out by trained health-care personnel. Today, 94% of women in Egypt arrange for their daughters to undergo this “medicalized” form of FGM, 76% in Yemen, 65% in Mauritania, 48% in Côte d’Ivoire, and 46% in Kenya. This approach may reduce some of the immediate consequences of the procedure (such as pain and bleeding) but, as WHO and UNICEF point out, it also tends to obscure its human rights aspect and could hinder the development of long-term solutions for ending the practice.
There has also been a lowering in some countries of the average age at which a girl is subjected to the procedure. (13) This could be to some extent the result of anti-FGM legislation: the younger the girl, the easier it is to elude legal scrutiny. Another possible adverse effect of legislation is, as often occurs with abortion, its tendency to drive FGM underground or encourage a cross-border movement of women from a country where the practice is illegal to a neighboring country where it is allowed.
One encouraging trend seen consistently in countries for which data from at least two surveys are available is that women aged 15–19 years are less likely to have been submitted to FGM than are women in older age groups. In almost all of these countries, support for the discontinuation of the practice is particularly high among a younger women.
Prevalence of FGM in women and daughters:
Notes: Countries are listed from higher to lower levels of FGM/C among women
Source: Female genital mutilation/cutting: a statistical exploration. New York, NY: UNICEF; 2005.
Ending female genital mutilation:
Since the middle of the last century many international and national organizations and agencies, both governmental and nongovernmental, have set up programmes to halt or reduce the prevalence of FGM. Thanks largely to their efforts, clauses prohibiting the practice have been incorporated into a large number of international legal instruments and into the legislation of a growing number of countries. Half of the 28 countries where the practice is “endemic” have introduced legislation forbidding it. A further seven countries have incorporated anti-FGM legislation into their constitutions or criminal laws. Applying the law, however, is another matter: a study published in 2000 found that prosecutions had been brought in only four of the 28 countries of Africa and the Middle East where FGM is practised. (12) Laws prohibiting FGM have also been introduced in several countries with immigrant communities continuing the practice: these countries include Australia, Canada, New Zealand, USA and at least 13 countries in Western Europe. Again, the annual rate of prosecutions varies widely.
Armed with arguments based on its danger to health and on its violation of human rights, opponents of FGM have, over the past half-century or so, tried various strategies—ranging from public education campaigns to offering alternative sources of income to FGM practitioners—aimed at stopping the practice. Some of the more successful strategies include:
? promotion of alternative “rites of passage” that preserve the ritual or symbolic component of FGM marking the admission of young girls into the community or into adulthood but without unduly harming their bodies;
? group discussions and media campaigns aimed at raising awareness among parliamentarians, religious and civic community leaders, traditional and modern health-care providers, and other decision-makers, as well as among the public, of the dangers to health and of the transgression of human rights that FGM involves;
? promotion, at all levels of society, of the abandonment of FGM as part of a “development package” that includes a reduction of poverty and of inequities and inequalities between the sexes, and an increase in access to education and health services.
A practice resistant to change:
In countries where FGM is unknown, people often react with incredulity that in this day and age FGM is still practiced despite its negative impact on health, its disregard of human rights and its illegality in many countries. Most surprisingly, the practice often persists even among families who agree that it should be
Abandoned. Social scientists say FGM persists for the following reasons:
- It endows a girl with cultural identity as a woman: in many ethnic groups the clitoris is associated with masculinity and is excised to maintain differentiation between males and females.
- It imparts on a girl a sense of pride, a coming of age and admission to the community: in many communities, girls are rewarded with gifts, celebrations and public recognition after the operation.
- Not undergoing the operation brands a girl as a social outcast and reduces her prospects of finding a husband.
- It is part of a mother’s duties in raising a girl "properly" and preparing her for adulthood and marriage.
- It is believed to preserve a girl’s virginity, widely regarded as a prerequisite for marriage, and helps to preserve her morality and fidelity: in some ethnic groups, virginity is associated with an infibulated vulva, not with an intact hymen.
- It is believed to enhance a husband’s pleasure during the sex act.
- It is believed to confer bodily cleanliness and beauty on a girl: in some communities, the female genitalia are considered unclean.
- It is believed to be prescribed
Summaries of the Laws of Some African Countries:
|
Burkina Faso: |
Burkina Faso has incorporated into its draft constitution a prohibition on female genital mutilation. |
|
Egypt: |
The position in Egypt is not clear. The educated community regards the practice as having been banned by President Nasser in 1958. Others say that partial clitoridectomy is allowed, but because of the confusion excision and infibulation are both still practiced in Egypt. For the most part legislation has not been effective in eliminating or reducing the practice of female genital mutilation in Africa, but this appears to have been due to problems of enforcement. |
|
Ivory Coast: |
In 1991, the Cote D'Ivoire (Ivory Coast) advised the United Nations that existing provisions of the nation's criminal code could be used to prohibit the practice. |
|
Kenya: |
In 1982 Kenyan President Moi condemned female genital mutilation and called for prosecution of those who practiced it. Kenya passed legislation banning female genital mutilation in 1990, but various forms of female genital mutilation are still practiced there. |
|
Sudan: |
In Sudan the Ministry of Health launched a campaign against female genital mutilation in 1946 and succeeded in getting a law passed prohibiting infibulations but allowing sunna. The law was primarily a response to pressure by British colonial powers and little action was taken to enforce it |