Medical Complications of Female Genital Mutilation

Abstract

More than 130 million women are subjected to genital mutilation. Despite increasing efforts to reduce the practice, there are many obstacles to eliminating this 2,000-year-old practice, which is based on strong cultural traditions. As college health clinicians provide care to more international students from countries where female genital mutilation is performed, increased awareness and knowledge of the procedure will enable clinicians to understand and manage its complications. We report a case of obstructive uropathy resulting in hydronephrosis secondary to female genital mutilation and review the medical literature regarding this and other complications of genital mutilation “surgery.”     

Female circumcision: the view from Sudan. Interview [with Ikhlas Nouh Osman

Female circumcision involves removing either all or part of the clitoris, labia minora, and/or labia majora. The practice is therefore increasingly being described as female genital mutilation. More than 90% of women in Sudan have undergone female genital mutilation. Pharonic circumcision is the most prevalent in Sudan. This form of mutilation involves the full removal of the clitoris and the labia. The two sides of the wound are then sewn together, leaving a small hole through which urine and menstrual blood may pass. Female genital mutilation occurs because women believe that the resultant narrow vaginal entrance will give pleasure to a future husband, due to tradition, uncircumcised women have great difficulty finding a spouse, and from the belief that the practice is mentioned in Islam. Koranic law is widely respected and followed in the Islamic areas of Sudan. Contrary to the belief of women that female circumcision keeps the vagina very clean, considerable health and psychological problems may result following the operation and throughout the woman's life. An activist against female genital mutilation describes her experience undergoing the operation, the trauma of first penile penetration with her husband, giving birth, and how women have their genital orifice restitched after delivery to the size before penetration. Nongovernmental organization efforts in Sudan against female circumcision are described.     

Local Rites and Body Politics

The growing awareness of violence against women has resulted in endorsement of various international codes and conventions relating to physical, psychological and sexual violence. Female genital mutilation is one form of violence against women that has polarized people within and across national borders. Here, I explore its popular representation, consider how activism against genital mutilation has been confounded by sex and race and how activism to eradicate the practice is understood by immigrant women in Australia. In doing this, I draw on research conducted with women immigrants to Australia from north Africa (the Sahel areas) and the Middle East, from countries where female genital mutilation is most common. These women are often frustrated by what they see as contradictions in hospital policy and practice that arise in response to their requests to be reinfibulated after childbirth. I tease out the dilemmas that emerge when refusal is contrasted with other permissible practices of the body, such as hymen reconstruction, and given the commodification of bodies and related issues of age and agency, the individual and the community. The perceived discrepancies suggest to these African women that rights discourse is discriminatory, racist and informed by sensational portrayals of traditional practices. I question the ethics, values and rights that inform public discourse about sexual and reproductive rights, when women’s rights and values are so discrepant from our own ideals.     

Labia Minora Elongation and its Implications on the Health of Women: A Systematic Review

ABSTRACT

Objectives: Labia minora elongation (LME) is a female genital modification practice categorized among the types included in the fourth group of female genital mutilation. In this article, we display the results of a systematic review of the evidence-based knowledge published on the health risks and benefits of LME as informed by African female respondents who are insiders of the practice. No other systematic review on this specific topic has been published before. Methods: A methodological bibliographic search was done in scientific databases by manual referencing and by contacting experts on this area of knowledge. Seventeen articles were eligible for this review, which corresponded to nine different studies. Eight of these studies were conducted in Eastern and Southern African countries and one was carried out in Italy. Results: This review concludes that pain at the beginning of the practice, nuisances related to the use of caustic herbs, and stigmatization in failing to comply with the practice are the principal health risks associated with LME. At the same time, there is evidence that labial elongation may benefit the sexual health and well-being of women. Conclusions: More research of a quantitative nature is necessary to determine the prevalence of LME across the practicing cultures and to determine its implications on the sexual and reproductive health of women who engage in this female genital modification.     

Socially Sanctioned Violence Against Women: Female Genital Mutilation Is Its Most Brutal Form

A historic survey indicates that Female Genital Mutilation occurs not only in the Third World but has also been practiced in the Occident. Though the differences in the practices, scope, and extent of the genital mutilations performed in these two divergent cultures are great, the basic goal has been the same. In the prevalent patriarchal societies, men sought and seek to curb, at times even eradicate, women's sexuality. Psychoanalytic findings indicate that the motive for female genital mutilation is based on men's unconscious fear of women's sexuality. The minimal psychic consequences following the mutilation of female genitals are loss of trust, a prevailing lack of bodily well-being, post-traumatic shock and depression.     

A case history based assessment of female genital mutilation in Sudan

The subject of female genital mutilation is discussed through a selection of excerpts from a narrative derived from interviews with educated Sudanese women. The original interview form ensures an inside, contextual presentation of the subject, providing the clues for approaches towards elimination of the practice. With evaluation and planning strategies in mind, the issues are placed in the conceptual framework of the segregation of the sexes and viewed through the ideas of gender-based discrimination as outlined in CEDAW.     

Final report on position of female circumcision in Nigeria

Survey data reveal that female genital mutilation (FGM) is being practiced in most Nigerian states, usually on babies and young girls but occasionally during wedding preparations or 7 months into the first pregnancy. Among the few tribes that mutilate women after marriage, husbands carry out the deed. Usually, FGM is performed on a group of girls, but it can also be performed on one girl in her home. The mutilator, who is paid a token fee, uses a knife or a razor. Post-mutilation treatment includes application of a variety of traditional methods. The most usual immediate complication is bleeding but other complications include tearing, septicemia, fistula development, stenosis, delayed second-stage labor, tetanus, urinary obstruction, and dyspareunia. Reasons cited for FGM include tradition, the belief that FGM curbs female promiscuity, and the belief that a baby whose head touches a clitoris during delivery will die. A prominent 1981 newspaper article on the subject reported the view of a physician that the practice ought to be eradicated and the view of a mutilator that it is not likely to be stopped.     

Implications of female genital mutilation on girls’ education and psychological wellbeing in Tarime,Tanzania

Though female genital mutilation is widely practiced in Tanzania, there has been no systematic examination of its long-term implications on girls’ wellbeing. Employing interviews and focus group discussions, this study explored the implications of female genital mutilation (FGM) on girls’ wellbeing in Tarime, Tanzania. The results revealed that the effect of FGM on girls are multifaceted, including early marriages, parents’ negative attitudes towards girls’ education, girls’ change in attitudes and loss of interest in schooling, which lead to poor educational achievement in many ways. Notably, girls who manage to escape FGM suffer from isolation and stigma from their peers who have been circumcised. Arguably, FGM is both a protective and risk factor for girls in Tarime. FGM is a protective factor against stigma and isolation for circumcised girls, and it is a risk factor in denying circumcised girls’ opportunities for education, and in perpetuating stigmatisation for the uncircumcised girls. We have concluded that, in the absence of more positive alternative rites of passage for adolescent girls in Tarime, and despite the widespread awareness about its negative consequences, FGM is likely to continue due to its centrality in the Kuryan cultural, social and economic necessities.     

Campaigning against female genital mutilation in Ethiopia using popular education

In Ethiopia, the Italian Association for Women in Development (AIDOS) has been working with Ethiopia's National Committee on Traditional Practices Affecting the Health of Women and Children for 5 years. AIDOS began working on female genital mutilation in the early 1980s and rejects charges of cultural imperialism that are applied to Northern organizations attempting to help African organizations address this violation of universal human rights. In Ethiopia, 85% of women are mutilated, with most undergoing Sunna, or removal of the prepuce of the clitoris. The joint project seeks to increase awareness about the health consequences of female genital mutilation in the target group. The primary technique used is provision of training of trainers courses and presentation of four modular units and audiovisual materials specifically designed for use with socially influential women, male and female secondary school students, community leaders, and health workers. In addition, an information/education campaign uses videos and sound and slide shows with accompanying story books. A second category of communication tools was developed for a mass information campaign, including radio spots, posters, information leaflets, and a newsletter. When the project was ready for expansion into the southern region of the country, it became clear that a new participatory communication strategy was required to stimulate discussion, such as the use of role playing and theater. Working together, the two organizations have successfully confronted project constraints such as the difficulty in assessing project impact, scheduling problems, and gender-biased assess to information.     

Female genital mutilation and human rights

Abstract

This article evaluates five different discourses on female genital mutilation for affinities with the language of international instruments codifying human rights: an activist physician's fieldwork journal; two novels, one a Lebanese-American's lyrical work largely indebted to a human rights perspective and, in contrast, a Kenyan publicist's fiction which mutes that approach; an American activist's auto-ethnography; paintings by Nigerian artists in an exhibition travelling in Germany; and a letter to the editor of an African American magazine. I read these varied lexica in light of recent literature on female genital surgery that tends to oppose academics, mainly anthropologists captive to their training, to activists impatient with post-modern wavering who claim that global instruments for women's human rights should be enforced to stop genital torture. Creative writing is instrumental in presenting a clear moral imperative confronted by the complexities of human lives.     

Clinical Management of Gender Dysphoria in Young Boys

In this study the clinical management of young boys (average age 6) who are gender identity disordered and who present with genital self injurious behavior is discussed. It is argued that the symptom of genital mutilation is often missed because it is not asked for in the clinical interview. A review of the literature, and case history material, suggests that the symptom of genital self injurious behavior is only found among children who are gender dysphoric. Young boys who experience severe gender dysphoria also have a serious affective disorder which must be addressed. In order to address the clinical emergency and to assist the families in getting the necessary treatment for their children specific recommendations for interventions are made.     

Like mother,like daughter? Female genital cutting in Minia,Egypt

Evidence that 97 percent of ever-married Egyptian women were circumcised in 1995 fueled interest to understand the levels, determinants, and consequences of this practice. Qualitative data suggest that ideologies of femininity, pressure to conform to behaviors characterizing womanhood, and constraints to other opportunities perpetuate women's support for female genital cutting in Minia, Egypt. While the practice remains prevalent in Minia, age-specific probabilities of genital cutting are lower among daughters than mothers and among younger than older daughters. A mother's education is negatively associated with, and her circumcision status positively associated with, her intent and decision to circumcise a daughter. Increasing reliance on doctors to perform the procedure is positively associated with urban residence and father's education, indicating a need to understand local meanings of modernity. Overall, increasing girls' access to higher education may contribute to further declines in female genital cutting in this setting.     

Sexual Abuse in Cameroon: A Four-Year-Old Girl Victim of Rape in Buea Case Study

A young girl was brought to the emergency unit after suffering sexual abuse by an older male. Additional abuses against women and girls include physical beating, forced marriage, female genital mutilation, breast ironing, widow’s rites, psychological abuse, and discrimination in education, finance, employment, and legal access. Cameroon has adopted strategies aimed at eliminating violence against women, including ratification of international policies, penal codes, and support of local and international efforts that promote women; however, many of the laws remain in name only and are rarely enforced, given women’s lack of financial access to quality lawyers and an unsympathetic male-dominated police force. Underreporting and culturally accepted abuses remain a challenge, too, as the country seeks to understand the extent of abuses and how to effectively fight against them. A complete paradigm shift in cultural attitude toward the female gender is required for abuses to cease.     

Changes in Sexual Distress,Depression and Sexual Function after Clitoral Reconstruction in Women with Female Genital Mutilation/Cutting

Abstract

Background: Female genital mutilation/cutting (FGM/C) links health complications and psychological distress. However, there is scarce literature on how women with FGM/C respond to treatment interventions. Objective: In this study, we aimed to assess changes in depression symptomatology, sexual function, and distress following clitoral reconstructive surgery combined with a psychoeducational intervention. Methods: The reconstructive surgery consisted of recovering the remaining clitoris and placing it externally and as close to the vagina as possible. FGM/C patients (n?=?27) received psychological support and sexual counseling upon undergoing the surgical intervention and were further assessed at 6-month follow-up. Moreover, they completed the Beck Depression Inventory and the Female Sexual Distress Scale Revised at these two time points. Patients’ sexual dysfunction was assessed according to DSM-5 criteria. Results: Statistically significant clinical changes after FGM/C were reported. Overall, patients presented reduced depression and sexual distress levels, and decreased female sexual interest/arousal disorder prevalence. Results also revealed that sexual distress improvements were more significant in Type I FGM/C patients. Conclusions: Significant improvements in sexual distress, psychopathology, and sexual function were observed in our sample following reconstructive surgery, suggesting that combined interventions are effective for treatment.     

Measurement of the sexual health and wellbeing of women who have undergone female genital mutilation/Cutting: A scoping review

Objective: We conducted a scoping review to identify and assess instruments used to measure sexual health and wellbeing in women who have undergone female genital mutilation/cutting (FGM/C). Method: We retrieved and assessed 10 validated instruments using an 18-item checklist derived from the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN) checklist. Results: All instruments were developed and initially validated among literate, predominantly Caucasian participants in North America and Europe. Only 1 validation study was conducted among women living with FGM/C. Conclusion: Most instruments only measured sexual functioning. Findings underscore the need to validate instruments appropriate for use among FGM/C survivors.     

UK Paramedics Confidence in Identifying Child Sexual Abuse: A Mixed-Methods Investigation

United Kingdom (UK) paramedics are in a prime position to identify children and young people who are victims or at risk of sexual abuse. Paramedics have access, by phone, or in person, to unprepared homes and communities which other health professionals such as social workers may not. Little research exists however, investigating UK paramedic confidence in identifying child sexual abuse. This mixed-method explanatory sequential investigation used the self-reported confidence levels of 276 UK paramedics to inform the design of seven semi-structured focus groups with 25 UK paramedics from a large ambulance service with operating models similar to all UK services. Multiple factors contribute to a lack of confidence in identifying child sexual abuse, child sexual exploitation, and female genital mutilation, including a perceived lack of exposure to sexual abuse, the perceived hidden nature of sexual abuse, and the lack of physical symptoms and examination. An overarching lack of knowledge is the most significant contributor to a lack of confidence which in turn perpetuates misinformation surrounding prevalence, location, and the signs and symptoms of sexual abuse. These findings suggest a lack of sufficient training and a need for further research evaluating the content of current training and its method of delivery.     

Working towards a world free from violence against women: UNIFEM's contribution

The UN Development Fund for Women (UNIFEM) has been at the forefront of the campaign to end violence against women. The Fund's premise is that there can be no sustainable communities or development without the attainment of peace and women's human rights. The UNIFEM Trust Fund in Support of Actions to Eliminate Violence Against Women was established in 1997, and, to date, has supported 59 projects in 49 countries related to the human rights abuse of women within families, war crimes against women, violations of women's bodily integrity (e.g., female genital mutilation), economic discrimination and exploitation, and political and legal discrimination. Program strategies include education, capacity building, violence prevention, the reversal of ingrained attitudes, and action-oriented research. In addition, regional awareness campaigns are conducted to introduce the issue of violence against women to the agendas of world governments. Finally, a learning component for the Fund analyzes the results of Fund initiatives and identifies ways of shaping more effective strategies for combating violence against women. Future areas of work include strengthening enforcement mechanisms in response to violence against women, upgrading the capacity to use international legal instruments, and facilitating information exchange.     

Conformity and change: community effects on female genital cutting in Kenya

In this article, I analyze women's decisions to have their daughters circumcised based on data from 7,873 women in Kenya collected in the 1998 Kenya Demographic and Health Survey. I use multilevel models to assess the degree to which women s decisions are correlated with the decisions of other women in their community, in addition to studying the effects of socioeconomic characteristics measured at both the individual and community levels. I find some support for modernization theories, which argue that economic development leads to gradual erosion of the practice of female circumcision. However, more community-level variation is explained by the convention hypothesis, which proposes that the prevalence of female circumcision will decline rapidly once parents see that a critical mass of other parents have stopped circumcising their daughters. I also find substantial variation among different ethnic groups in the pace and onset of the decline of female genital cutting.     

Zambian Women in South Africa: Insights Into Health Experiences of Labia Elongation

Labia minora elongation consists in the manual stretching of the inner lips of the external genitalia. This practice is documented in east and southern Africa. The experiences of African women in the diaspora practicing elongation are not thoroughly understood. The purpose of this qualitative study was to explore the health harms and benefits associated with this practice of Zambian women who have migrated to Cape Town, South Africa. Twenty women and seventeen men participated in this study. Between December 2013 and May 2014, in-depth interviews and natural group discussions were conducted with the participants. The focus of this article is to report on the emic of the women related to notions of health, hygiene, and well-being. Labial elongation is perceived as a practice involving minor, short-term adverse effects that can be prevented by following some basic hygiene. Overall, personal and social value is placed on this practice because of its reported benefits for the sexual health of men and women, and for women's femininity and self-image. Further research is necessary on how female genital modifications influence Zambians’ sexual preferences to inform the development of culturally appropriate health promotion interventions.