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Saturday, December 4, 2021

Female Genital Mutilation/Cutting: the facts, the bad and the ugly

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Are you a victim of FGM? How has this impacted your livelihood? Have you ever wished you could change the hands of time? Are you willing to fight against it? How many other children must suffer the same fate as you did?

February 6th, 2021, was the International day of zero tolerance for FGM. It was also a gloomy day for a 25y/o police officer who presented in labour at the Edward Francis Small Teaching Hospital (EFSTH). She had undergone Type 3 FGM and had a very difficult labour. Her husband (Daddy, like she calls him) was very supportive and stayed with her throughout the course of giving birth. Her vaginal orifice was so narrow that it made the whole labour unbearable, inciting an excruciating pain that only she could muster. Daddy being so observant asked why was she so tight? FGM, I answered. Looking into the depths of his wife’s eyes, he vowed to not allow his girls suffer the same fate.

What is FGM? FGM comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reason (WHO 2020).

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The practice is mostly carried out by traditional circumcisers (95.7% in The Gambia), who often play other central roles in communities, such as attending childbirths. FGM is recognized internationally as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person’s rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death.

In The Gambia, the prevalence of FGM in women aged 15-49 is 74.9%. Basse has the highest prevalence (96.7%) and the lowest prevalence (47.7%) is found in Banjul. 54.8% of women aged 15-49 were cut before the age of five, 28.1% between the ages of five and nine (28toomany.org). Quite alarming, right!?

Types of FGM

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•          Type 1:  this is the partial or total removal of the clitoral glans (the external and visible part of the clitoris, which is a sensitive part of the female genitals), and/or the prepuce/ clitoral hood (the fold of skin surrounding the clitoral glans).

•          Type 2:  this is the partial or total removal of the clitoral glans and the labia minora (the inner folds of the vulva), with or without removal of the labia majora (the outer folds of skin of the vulva).

•          Type 3: Also known as infibulation, this is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoral prepuce/clitoral hood and glans (Type I FGM).

•          Type 4: This includes all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.

Type 1, is the most common type of FGM practiced in The Gambia. FGM has no health benefits, and it harms girls and women in many ways. It involves removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls’ and women’s bodies. Generally speaking, risks of FGM increase with increasing severity (which here corresponds to the amount of tissue damaged), although all forms of FGM are associated with increased health risk.

Complications

•          severe pain

•          excessive bleeding (haemorrhage)

•          genital tissue swelling

•          fever

•          infections e.g., tetanus

•          urinary problems

•          wound healing problems

•          injury to surrounding genital tissue

•          shock

•          death.

Long-term complications can include:

•          urinary problems (painful urination, urinary tract infections);

•          vaginal problems (discharge, itching, bacterial vaginosis and other infections);

•          menstrual problems (painful menstruations, difficulty in passing menstrual blood, etc.);

•          scar tissue and keloid;

•          sexual problems (pain during intercourse, decreased satisfaction, etc.);

•          increased risk of childbirth complications (difficult delivery, excessive bleeding, caesarean section, need to resuscitate the baby, etc.) and newborn deaths;

•          need for later surgeries: for example, the sealing or narrowing of the vaginal opening (Type 3) may lead to the practice of cutting open the sealed vagina later to allow for sexual intercourse and childbirth (deinfibulation). Sometimes genital tissue is stitched again several times, including after childbirth, hence the woman goes through repeated opening and closing procedures, further increasing both immediate and long-term risks;

•          psychological problems (depression, anxiety, post-traumatic stress disorder, low self-esteem, etc.);

The reasons why female genital mutilations are performed vary from one region to another as well as over time, and include a mix of sociocultural factors within families and communities. The most commonly cited reasons are:

•          Where FGM is a social convention (social norm), the social pressure to conform to what others do and have been doing, as well as the need to be accepted socially and the fear of being rejected by the community, are strong motivations to perpetuate the practice. In some communities, FGM is almost universally performed and unquestioned.

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

•          FGM is often motivated by beliefs about what is considered acceptable sexual behaviour. It aims to ensure premarital virginity and marital fidelity. FGM is in many communities believed to reduce a woman’s libido and therefore believed to help her resist extramarital sexual acts. When a vaginal opening is covered or narrowed (Type 3), the fear of the pain of opening it, and the fear that this will be found out, is expected to further discourage extramarital sexual intercourse among women with this type of FGM.

•          Where it is believed that being cut increases marriageability, FGM is more likely to be carried out.

•          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 unclean, unfeminine or male.

•          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. Likewise, when informed, they can be effective advocates for abandonment of FGM.

•          In most societies, where FGM is practised, it 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 neighbouring groups. Sometimes it has started as part of a wider religious or traditional revival movement.

Sixty-five percent of women who have heard of FGM think the practice should continue. A national decree/legislation banning FGM/C was passed in 2015, however the practice still continues. Ending FGM requires decisive action from the government, civil society, religious and cultural leaders and the entire communities.

What are you doing today to end FGM?

Jainaba Jallow is a 6th year medical student at the University of The Gambia School of Medicine and Allied Health Sciences. She is also the IPRO of Medical Students’ Association of UTG.

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