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NETWORK AGAINST GENDER BASED VIOLENCE (NGBV)’S POSITION PAPARON THE FEMALE GENITAL MUTILATION/CIRCUMSCISSION (FGM/C) MATTERPRESENTED TO THE NATIONAL ASSEMBLY JOINT COMMITTEE ON 8TH MAY 2024:

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Introduction:

According to World Health Organizations definition, FGM/C refers to the partial or total removal of external female genitalia or other injury to the female genital organs for non-medical reasons. FGM/C is a harmful practice that violates the human rights and undermines the health and well-being of girls and women worldwide. WHO estimated that over 200 million girls and women worldwide have undergone FGM/C, and approximately 3 million girls are at risk of undergoing the practice.

Types of FGM in The Gambia

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·           Type I: Excision of the prepuce, with or without excision of part or all of the clitoris.

·           Type II: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora.

·           Type III: Infibulation of part or all of the external genitalia and stitching/narrowing of the vaginal opening, with or without the removal of the clitoris and labias.

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In The Gambia, FGM/C is also referred to as female circumcision by the Women’s (Amendment) Act 2015 as commonly known in Gambian communities. According to the Demographic Health Survey (GBoS 2019/2020), 73% of women aged15-49 are circumcised, a slight decrease from 2013 DHS (75%). Despite national efforts to eliminate the practice in The Gambia for almost four decades (since 1980s), FGM/C persists in many Gambian communities due to deep-rooted traditional, social, and religious beliefs. According to the Demographic Health Survey (DHS) 2019/2020, the most common type of FGM/C in The Gambia is Type II (some flesh removed), with 73% of circumcised women undergoing this procedure. Seventeen percent (17%) of women underwent Type III procedure (also known as infibulation or sealing). Only 1% of women underwent Type I procedure (clitoris nicked). Thus, the DHS 2019/2020 confirmed to us that what more than 90% of our women and girls who underwent FGM/C have been subjected to type II and III which both have serious health consequences on them.

FGM/C IMPACT ON THE HEALTH OF WOMEN AND GIRLS

FGM/C poses severe physical, psychological, and emotional consequences for affected individuals. Evidence from researches conducted in The Gambia and other parts of the world have showed that the practice violates women and girls’ sexual and reproductive health and rights including right to choose and dignity. Immediate risks include severe pain, bleeding, infections, and even death, while long-term complications encompass chronic pain, urinary problems, sexual dysfunction, obstetric complications and psychological trauma.

Honorable NAMs, in 2017 clinical research on the ‘Obstetric Outcome of FGM’ on pregnant women in The Gambia was commissioned by Network Against Gender Based Violence (NGBV) and ActionAid International The Gambia in partnership with the Ministry of Health. The study was conducted in four major health facilities which include Edward Francis Small Teaching Hospital (EFSTH), Jammeh Foundation for Peace Hospital (JFPH), now call Bundung Maternal and Child Health Hospital, Brikama District Hospital, and Bansang General Hospital. The study was done by Gambian Doctors and Nurse Midwives working at the above-named hospitals. The on-site Investigators were Dr. Neneh Bah and Dr. Awa Jah of EFSTH, Dr. Dado Jabbi of Jammeh Foundation for Peace Hospital now known as Bundung Maternal and Child Health Hospital, Dr. Lukas Jatta of Brikama District Hospital and Dr. Momodou T. Nyassi of Bansang Hospital. They were supported by sixteen senior Nurse Midwives who were working at the labour wards of these hospitals. These Gambian doctors and midwives were trained and guided by Specialists including Dr. Patrick Idoko, a Gyneacologist and Dr. Mustapha Bittaye, a Gyneacologist and Research Clinician at EFSTH and Dr. Olubukola Idoko, a Paediatricians and Research Clinician at MRC amongst others. A total of 1,569 women participated in the study.

?          23% had no FGM/C

?          77% had FGM/C out of which:

1)         23.8% had undergone FGM/C type I

2)         44.8% had undergone FGM/C type II

3)         8.4% had undergone FGM/C type III/IV

?          Only 6 cases of type IV FGM/C were recruited into the study.

?          The age range of study participants were from 18 to 46 years.

?          39.2% live in the rural areas while 60.8% lived in urban areas.

According to the report of this clinical study on FGM:

·    Women with FGM/C are more likely to have blood loss of 500ml or more after delivery and the risk increases with the severity of the type of FGM/C.

·      Women with FGM/C are more likely to have undergone operation during childbirth with the risk increasing based on the severity of the FGM/C type.

·    Women with FGM/C are more likely to have perineal laceration (tears) or episiotomy (a cut through the area between the vaginal opening and anus to aid childbirth) with the risk increasing based on the severity of the FGM/C type.

·      Most women suffer in silence as they hesitate to express pain related to childbirth and to FGM/C, noting that open discussion of sexual and reproductive health is hindered by norms related to privacy and projecting strength.

·     Women are not the primary decision makers on matters Concerning their own sexual and reproductive rights.

OUR POSITION

The position of NBGV, and larger CSOs in The Gambia is for the ban on FGM/C to remain. Based on the evidence presented above and the ‘Do No Harm’ principle of the medical profession, FGM/C should not be medicalized. The National Assembly should listen to the voices of reason, and consider the health implication highlighted by professional health workers, and reject the Women’s (Amendment) Bill 2024. This will empower affected individuals and communities, strengthen the health rights and dignity of survivors and facilitate the eradication of the practice.    

Honourable NAMs, various justifications, both socially and religiously have been attached to the practice of FGM. However, the reasons given cannot be justified considering the evidence that has been presented to you which showed the practice violates women’s sexual and reproductive health and rights.

As a human rights network, NGBV promotes and defend right to religious practice. The campaign to not lift the ban on FGM/C is not anti-islamic, rather based on the Islamic teaching of Do No Harm.  Furthermore, from an Islamic point of view, Islam prioritizes health. This is why, Muslims who are not healthy enough to fast or to perform Hajj are exempted from these religious obligations based on professional medical doctor’s advice. Based on this Islamic Do No Harm principle, the practice of FGM/C should be banned in The Gambia.

OUR CALL:

In our quest to address the FGM/C problem, NGBV and the CSO Coalition call on the National Assembly and the Executive to:

·           Ensure The Women’s (Amendment) Act 2015 banning FGM/C remains as a law in The Gambia to protect Gambian Women and Girls from FGM/C.

·           Amplify community engagements and awareness raising on the health consequences of FGM/C to empower communities/ constituencies to abandon the practice.

·           Strengthen police and other law enforcement agencies to maintain and implement the Women’s (Amendment) Act 2015 to deter communities from practicing FGM/C and protect women and girls from the harmful effects of FGM/C.

In that regard, it is imperative on Government of The Gambia in general and the National Assembly to be precise, as lawmakers and representatives of people including women and girls to protect their fundamental right to health. Over the past few months, The Gambia has been tested on the FGM/C issue as we were tested in the past during the impasse after the 2016 Presidential election and as a peace-loving people we passed the test. Today we are tested again and as the primary duty bearer, the National Assembly, we urge you to look at the best interest of our women and daughters by critically considering the plight and rights of innocent souls, our little girls, who are vulnerable and could not protect themselves or make a choice for themselves in this matter. We appeal to you to selflessly think of them while you make a decision to ensure that you are guided by the “Best Interest Principle” as enshrined in the Children’s Act 2005.

CONCLUSION:

Understandably, The National Assembly has a tough responsibility. A responsibility that includes shaping society, its culture, and behaviour. FGM/C is a deeply-rooted cultural practice, and many also argued it’s a religious one. However, the decision National Assembly Members should take in this matter has been made by the 5th legislature – banning FGM/C. Today, the 6th legislature has responsibility to maintain the ban in order to protect women and girls in this country.

Mr. Fallu Sowe

National Coordinator

Network against Gender Based Violence

8th May 2024.

Reference: 

WHO Website: https://www.who.int/health-topics/female-genital-mutilation#tab=tab_1

Demographic and Health Survey (GBoS2019/2020):  https://dhsprogram.com/pubs/pdf/FR369/FR369.pdf

Obstetric Outcome of Female Genital Mutilation 2017: https://gambia.actionaid.org/sites/gambia/files/publications/Obstetric%20outcome%20of%20FGM_final.pdf

Female Genital Cutting in The Gambia – Gambian Gynaecologists reaction

(correspondence: [email protected])

Over the last couple of months, there has been a national debate on the appropriateness of female genital cutting in The Gambia. Most of the discussion have focused on personal opinions of interested stakeholders on the topic. As gynaecologists and doctors working in women’s health, this is our contribution to the discussion.

Female genital cutting is currently performed in The Gambia by practitioners with no formal medical training without anaesthesia and often using crude instruments in environments that do not meet the minimum health and safety standards.

Modern medical practice has moved beyond the opinion of respected authorities to evidencebased medicine. In the hierarchy of evidence-based medicine, the opinion of respected authorities in the field is rated much lower than peer-reviewed observational studies. The highest level to source for evidence is systematic reviews and meta-analysis. There have been several systematic reviews and meta-analysis on the health effects of female genital cutting (Saryloo et al 2019). Professionals may have their individual opinions about female genital cutting but it cannot supersede observational studies or systematic reviews.

Because of the way in which female genital cutting is performed, there is immediate risk of significant bleeding, injury to vital organs like the urethra, infection and fever. In a systematic review by Berg (Berg 2014), the most common immediate complications were bleeding, acute inability to urinate and swelling around the genital area. 

Long term health consequences of female genital cutting have also been well documented.

Genital scarring and neuromas of the clitoris causing severe pain have been described in The

Gambia by Kaplan as well as in other studies (Kaplan 2013). Several of us practicing in the Gambia have had to surgically remove large masses (epidermoid inclusion cysts and sebaceous cysts) caused by female genital cutting. Such swellings have been reported in the literature as well (see Asante et al 2010). In Berg’s systematic review, urinary tract symptoms and impaired sexual functions were significantly related with female genital cutting (see also Alsibiani 2010).

In a large study conducted by the World Health Organization (WHO) in 6 African countries that studied 28,000 women, female genital cutting was associated with more haemorrhage, increased risk of caesarean section, still birth and excessive bleeding after childbirth (WHO 2006). The findings from this large study are similar to a local observational study done in the Gambia by Idoko et al (Idoko 2022). Berg et al in a meta-analysis reported an increased risk of prolonged labour, postpartum haemorrhage and perineal trauma (Berg 2012).

Most of us practicing in The Gambia have also reported psychological problems associated with female genital cutting. Anxiety, flashbacks and post-traumatic stress disorder have been reported in women with female genital cutting (Vloeberghs 2012). As a society we must not minimize the mental health of women.

Some have advocated that type 1A female genital cutting (hoodectomy or removal of the prepuce) is harmless and even beneficial and should be practiced within the healthcare system in The Gambia akin to male circumcision. We must note that we have not found robust research for the benefit of type 1A female genital cutting (hoodectomy). The external genital in a female infant is very small and the anatomic structures may be quite difficult to delineate. The risks associated with performing this procedure in children is therefore significant even in a hospital environment. 

Clitoral hood reduction surgery (hoodectomy) belongs to a group of surgical procedures referred to as female genital cosmetic surgery. While consenting adult women who choose to have removal of the clitoral hood (type 1A) may have the freedom to do so by properly trained physicians, we align ourselves with the statement of the American College of Obstetricians and Gynaecologists (ACOG) on female genital cosmetic surgery.  The 2020 ACOG statement concludes that this procedure is not medically indicated, poses substantial medical risk and their safety and effectiveness have not been established. Moreso, we are concerned about the strain that will be added to our already burdened public healthcare system if hoodectomy is practiced in our public health facilities. In fact, resources will have to be diverted from other life-saving services to cater for hoodectomy in our public health system. Therefore, this may lead to public harm in the long run. 

A fundamental principle of medical ethics is to do no harm. We believe it will be unethical for any physician to perform female genital cutting. We will therefore urge the law makers to leave the current laws on female genital cutting as it is. If any part of this law is amended, significant harm to the anatomy and mental health of women is inevitable.

This statement is endorsed by the following:

1.         Dr. Patrick Idoko Senior Consultant Gynaecologist

2.         Dr Hassan Azadeh Senior Consultant Gynaecologist

3.         Dr Mustapha Bittaye Senior Consultant Gynaecologist and Director of Health Services

4.         Dr Matthew Anyanwu Senior Consultant Gynaecologist

5.         Dr Jose Green Harris Specialist Gynaecologist and Head of Clinical Services at Kanifing General Hospital

6.         Dr Awa Jah Specialist Gynaecologist

7.         Dr Fatoumata Jarjusey Specialist Gynaecologist

8.         Dr Kebba Gassama Specialist Gynaecologist

9.         Dr Dado Jabbie Specialist Gynaecologist and Head of Department at Bundung Maternal and Child Health Hospital

10.       Dr. Barrister Babanding Daffeh Senior Medical Officer and Head of Department at Kanifing General Hospital

11.       Dr Lucas Jatta Senior Medical Officer Brikama District Hospital

12.       Dr Elizabeth Innis Gynaecologist

13.       Dr Awa Sanyang Gynaecologist

Notes:

1.         Saryloo K, Roudsari RL, Elhadi A. Health consequences of the female genital mutilation: a systematic review. Galen Med Journal.2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8343977/#

2.         Berg RC, Underland V, Odgarrd-Jensen J, Fretheim A, Vist GE. Effects of female genital cutting on physical health outcomes: a systematic review and meta-analysis. British Medical Journal Open 2014;4:e006316

3.         WHO study group on female genital mutilation and obstetric outcome. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet. 2006;367:1835-41

4.         Idoko P, Armitage A, Nyassi MT, Jatta L, Bah N, Jah A, Jabbie D, Bittaye M. Obstetric outcome of female genital mutilation in The Gambia – an observational study. Afri Health Sci. 2022;22(4). 386-395. https://dx.doi.org/10.4314/ahs. v22i4.44

5.         Kaplan A, Forbes M, Bonhoure I, Utzet M, Martin M, Manneh M, et al. Female genital mutilation/cutting in The Gambia: longterm health consequences and complications during delivery and for the newborn. International journal of Womens Health 2013;5:323-31

6.         Asante A, Omurtag K, Roberts C. Epidermal inclusion cyst of the clitoris 30 years after female genital mutilation. Fertil Steril 2010;94:1097.e1-3

7.         Berg RC, Denison E. Does female genital mutilation /cutting  (FGM/C) affect women’s sexual functioning? A systematic review of the sexual consequences of FGM/C. Sex Res Social Policy 2012;9:41-56

8.   Alsibiani SA, Rouzi AA. Sexual function in women with female genital mutilation. Fertil Steril 2010;93:722-4

9.  Vloeberghs E, van der Kwaal A, Knipscheer J, van den Muijsenbergh M. Coping and chronic psychosocial consequences of female genital mutilation in The Netherlands. Ethn Health 2012;17:677-95

10. ACOG 2020. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/01/elective-female-genitalcosmetic-surgery  

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