Background about female genital mutilation

What Is Female Genital Mutilation (FGM)? 

• Procedures that alter or injure female genitalia for non-medical reasons
• No health benefits for girls and women who undergo this procedure 
• Mostly carried out between infancy to 15 years of age 
• 100 - 140 million girls around the world are living with the consequences of FGM
• In Africa, an estimated 92 million girls have undergone this procedure 

"FGM IS RECOGNIZED AS A VIOLATION OF THE HUMAN RIGHTS OF GIRLS AND WOMEN INTERNATIONALLY"

(WHO, 2010)

Taken from: http://www.medicine4faith.net/wp-content/uploads/2010/03/female-circumcision.jpg

Who performs the procedure?

• Often performed by traditional circumcisers who have central roles in communities
• local midwives or senior village women

• There is an increase in FGM being performed by health care providers.

FGM is classified into 4 types:

1. Clitoridectomy:
• Partial or total removal of the clitoris
• Rarely remove only the prepuce (fold of skin surrounding clitoris)
2. Excision:
• Partial or total removal of the clitoris and labia minora, with or without the removal of the labia majora (“lips” that surround the vagina)
3. Infibulation: 
• Most severe form of mutilation 
• Narrowing of the vaginal opening through a creation of a covering seal
4. Other: 
• Pricking, piercing, incising, scraping, and cauterizing of the genital area

(WHO, 2010)

Taken from: http://www.globalpulsejournal.com/blog/wp-content/uploads/2010/09/fgm-instruments.jpg

Procedure and equipment  

• In villages

• knives, old razor blades, broken glass, and sharp stones are used

• In local health clinics

• scalpels are used to perform FGM
• tools are often unsterilized and the procedures are performed without anesthesia

Why does female genital mutilation happen?

• Due to a mix of cultural, religious, and social factors within families and communities

• Unclear of when and where this practice first started, but it has existed for over 2000 years

• Social pressure to conform in certain cultures

• FGM is considered a fundamental step in raising a girl properly, and a way to prepare her for adulthood and marriage. 
• A woman is considered respectable and virtuous if she undergoes this procedure.

• FGM is intended to preserve the girl’s virginity until she is married. 

• The sewing of the vagina is performed to discourage any pre-marital sexual behavior by instilling fear of the pain of opening the vagina and the fear that she will be found out.

• Men who come from the areas where FGM is practiced will view an uncircumcised woman as being immoral and disgusting.

• FGM is considered to be the culture’s ideal view of femininity and modesty. The girls are considered to be “clean” and “beautiful” after the removal of body parts that are considered to be “male” or “unclean”

Why is this a nursing issue/ problem?

This is a nursing issue/ problem because:

• There are no health benefits for performing FGM, only harm is caused to girls and women who undergo this procedure
• Removal or damaging of healthy and normal female genital tissue will affect the normal/ natural functioning of a girl’s / woman’s body
• Some immediate side effects:          
• Severe Pain
• Shock
• Hemorrhage
• Tetanus
• Sepsis
• Urine retention
• Open sores in genital region
• Injury to surrounding genital tissue
• Long-term consequences
• Recurrent bladder and urinary tract infections
• Incontinence
• Painful menstruation
• Painful sexual intercourse
• Cysts
• Infertility

Taken from http://religionnerd.com/wp-content/uploads/2010/04/FGM-Anti-FGM.jpg

• Other issues

• Increased risk of childbirth complications and newborn deaths
• Need for further surgeries
• e.g. repeated sewing and surgical re-opening of vaginal opening
• emotional and psychological side effects that these women who undergo genital mutilation may go through in silence.
• misunderstanding and ridicule of these cultures that perform FGM by other nations who look at this practice as immoral and sadistic

What is the work that has been done to date about this issue?

The work that has been done to date is:

• UK 
• 1985: FGM is an illegal process and if a person is found to be carrying out this act, he / she can go to jail 
• 5-14 years
• FGM ACT: a bill was passed in 2003

• Twelve industrialized countries that receive immigrants from countries where FGM is practiced have criminalized the practice.

• African Nations that have criminizalized FGM:
• Benin (2003) 
• Burkina Faso (1996) 
• Central African Republic (1966) 
• Chad (2003) 
• Côte d'Ivoire (1998) 
• Djibouti (1994) 
• Egypt (2008) 
• Eritrea (2007)
• Ethiopia (2004)
• Ghana (1994) 
• Guinea (1965, 2000)  
• Kenya (2001)
• Mauritania (2005) 
• Niger (2003)
• Senegal (1999) 
• South Africa (2005) 
• Tanzania (1998)  
• Togo (1998)
• WHO is working with these countries and is trying to reduce and eliminate FGM, while educating the population as well.
•  Programs created: 
• Child and Adolescent Health Program
• Gender, Women's Health and Aging Program
• Making Pregnancy Safer Program
• Sexual and Reproductive Health Program

• There are an estimated 66000 women in the UK that are affected by FGM
• The Acton African Well Woman Centre officially opened in December 2008.

Taken from: http://2media.nowpublic.net/images//34/6c/346cdfc1a355df6c5257aab24eb048ff.jpg

What are the possible solutions to this problem?

Some possible solutions are:

• Providing a framework for the care for women with FGM, to be implemented by each European Union Member State (Leye, Powell, Nienhuis, Claeys & Temmerman, 2006).

• In Germany in 1999, Dr. Groh suggested a “new’’ technique
  • an incision in the clitoral hood without cutting  (Groh, 1999 as cited in Leye, et al., 2006).
• less drastic procedures are possible

• A harm-reduction strategy can be used by having the procedure performed by skill professionals: 

• Under hygienic circumstances with anesthetics (Shell–Duncan, 2001 as cited in Leye, et al., 2006)

Taken from: http://farm3.static.flickr.com/2682/4083807851_c66b9943f0.jpg

The European Union identified three health interventions:

1. Technical guidelines for the clinical management of women with FGM  
2. Codes of conduct for health care professionals published by professional associations on quality of care issues (e.g., culturally appropriate care) 
3. Specialized health services that provide medical care, psychological care, and counseling (Leye, et al., 2006).

Canadian Nurse (2010) recommends the following to eliminate FGM:

• complex social change
• a multidisciplinary approach that:
• respects the importance of cultural traditions
• fosters active engagement about the issue from men
• identifies employment options for women who currently earn their living performing the procedure (Canadian Nurse, 2010).
• An alternative approach to FGM is Ntanira Na Mugambo or "circumcision through words".
• It includes a week-long program of counselling, training, and providing of information to young women, ending with the "coming of age" day, when members of the community gather for a celebration with music, dances, and feasting.
• Since its initiation in Kenya in August, 1996, about 300 women have experienced this rite as an alternative to the traditional FGM.
• The key to its success is that it involves the adolescents, family members and the community’s participation in the design of the project.
• Men receive training on the negative effects of FGM for women, and they have to commit themselves to not require that their future wives be circumcised

What steps need to be taken to change nursing practice as a result of your inquiry?

Nurses must:

• research, learn and understand the cultural beliefs that guide such practices
• e.g. female genital mutilation “guarantee[s] the ‘membership’ of girls in the community” (Sala & Manara, 2001, p. 3).

• cast aside own values, beliefs and morals when working with such vulnerable clients, and not pass judgment 

• find a common ground “between respect for the tradition and cultural identity and the corporate value and bodily integrity of the individual” (Sala & Manara, 2001, p. 3).
• e.g. suggesting to client and family that less radical procedures may be done, while still preserving and respecting their cultural practices

• conduct a thorough discussion and teaching session with clients and family about such practices, less radical procedures, resulting negative health outcomes from having such procedures done, and management of such health outcomes

• constantly be aware of the issue of respect of cultural rights and human rights
• “promote individual rights and freedom” (Sala & Manara, 2001, p. 4)
• recognize that some of the articles in the Universal Declaration of Human Rights (UDHR), show that infibulation (surgical closure of the labia) violates such human rights (Sala & Smith, 2001)

• being aware of broader and more serious issues, such as:
• gender equality and power differentials
• cultural identity and social pride
• social inclusion

Taken from: http://files.coloribus.com/files/adsarchive/part_1127/11274355/file/amnesty-international-white-rose-small-47380.jpg

Basically, “[respect] the [clients] and their families… [and help] parents respect the dignity and freedom of their daughters” (Sala & Manara, 2001, p. 10).