Fgm

INTRODUCTION Female genital mutilation is the term now generally accepted for the traditional practices that entail removal of part or all of, or injury to the external genitalia of girls and women. It does not include genital surgery performed for medically prescribed reasons. The term was first used by feminists, women’s health advocates and human rights activists and was subsequently adopted by the Inter African Committee at a meeting in Addis Ababa, Ethiopia (1990). Since then, it has also been adopted by the United Nations and is increasingly being used by the public. Prior to its adoption, the practices were referred to as “female circumcision” a term still in common use. The terminology used to describe the different forms of female genital mutilation varies widely among the population groups where they are practiced and among researchers, health personnel, health advocates and others. Removal of the prepuce has been called “true circumcision”, in that it is equivalent to male circumcision. Clitoridectomy is sometimes referred to as “mild circumcision” and is also known as “Sunna circumcision” by some Muslim communities. However, the Koran does not recommend any form of female genital mutilation and it is suggested that, in order to prevent any misunderstanding that there is such a link, the term “Sunna” should be discouraged. Infibulations may be termed “severe circumcision” and is also known as “Pharaonic circumcision” in Sudan and “Sudanese circumcision” in Egypt. A modified form of infibulation has been called “intermediate circumcision”. Attempts to classify female genital mutilation also vary considerably, since the different types of procedure have never been clearly defined. The classifications in current use generally distinguish three main types:  Excision of the prepuce and clitoris  Excision of the prepuce, clitoris and labia minora  Infibulation Some classifications also include other procedures such as introcision. CONSEQUENCES OF FEMALE GENITAL MUTILATION The health implications or consequences of female genital mutilation could be divided into physical, sexual, mental and social. 1. PHYSICAL CONSEQUENCES Female genital mutilation causes grave damage to girls and women and frequently results in short and long term health consequences. The effects on health depend on the extent of cutting, the skill of the operator, the cleanliness of the tools and the environment, and the physical condition of the girl or woman concerned. Girls and women undergoing the more severe forms of mutilation are particularly likely to suffer serious and long-lasting complications. Documentation and studies are available on the physical short-term and long-term complications described below, but there has been little study of the sexual or mental effects or of the frequency with which complications occur. The mortality of girls and women undergoing genital mutilations is unknown, as few records are kept and deaths due to the practice are rarely reported. a. SHORT – TERM COMPLICATIONS • Pain. The majority of mutilation procedures are undertaken without anaesthetic agents and cause severe pain. Even in a medical setting where local anaesthesia is available, it is difficult to administer as the clitoris is a highly vascular organ with a dense concentration of nerve endings; to anaesthetize the area completely, multiple painful applications of the needle are required. • Injury to adjacent tissue of the urethra, vagina, perineum and rectum can result from the use of crude instruments, poor light, poor eyesight of the practitioner or careless technique. This is even more likely if the girl is screaming or struggling because of pain or fear. Damage to the urethra can result in urinary incontinence. • Heamorrhage. Excision of the clitoris involves cutting the clitoral artery which has a strong flow of blood with high pressure. Packing, tying or stitching to stop bleeding may not be effective and this can lead to heamorrhage. Secondary heamorrhage may occur after the first week as a result of sloughing of the clot over the artery due to infection. Cutting of labia causes further damage to blood vessels and Bartholin’s glands. Heamorrhage is the most common and life threatening complication of female genital mutilation. Extensive acute haemorrhage or protracted bleeding can lead to anaemia or heamorrhagic shock and in some cases death. • Shock. Immediately after the procedure, the girl may develop shock as a result of the sudden blood loss (haemorrhagic shock) and severe pain and trauma (neurogenic shock), which can be fatal.

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Acute urinary retention can result from swelling and inflammation around the wound, the girl’s fear of the pain of passing urine on the raw wound, or injury to the urethra. Retention is very common; it may last for hours or days, but is usually reversible. This condition often leads to urinary tract infection. • Fracture or dislocation. Fractures of the clavicle, femur or humerus or dislocation of the hip joint can occur if heavy pressure is applied to the struggling girl during the operation, as often occurs when several adults hold her down during the mutilation. • Infection is very common for a number of reasons; unhygienic conditions, use of unsterilized instruments, application of substances such as herbs or ashes to the wound, which provide an excellent growth medium for bacteria, binding of the legs following type III female genital mutilation (infibulation), which prevents wound drainage or contamination of the wound with urine and/or faeces. Infections can result in failure of the wound to heal, abscess, fever, ascending urinary tract infection, pelvic infection, tetanus, gangrene or septicaemia. Severe infections can be fatal. Group mutilations, in which the same unclean cutting instruments are used on each girl may give rise to a risk of transmission of blood borne diseases such as HIV and hepatitis B. The consequences of type III mutilation, such as repeated cutting and stitching during labour, and the higher incidence of wounds and abrasions during vaginal intercourse and increased anal intercourse because of the difficulties of vaginal penetration may also potentially increase the risk of HIV transmission. • Failure to heal. The wounds may fail to heal quickly because of infection, irritation from urine or rubbing when walking, or an underlying condition such as anaemia or malnutrition. This can lead to a purulent, weeping wound or to a chronic infected ulcer. b. LONG-TERM COMPLICATIONS • Difficulty in passing urine can occur due to damage to the urethral opening or scarring of the urethral meatus. • Recurrent urinary tract infection. Infection near the urethra can result in ascending urinary tract infections. This is particularly common following type III mutilation, when the normal flow of urine is deflected and the perineum remains constantly wet and susceptible to bacterial growth. Stasis of urine resulting from difficulty in micturition can lead to bladder infections. Both types of infection can spread to the ureters and kidneys. If not treated, bladder and kidney stones and other kidney damage may result. • Pelvic infections are common in infibulated women. They are painful and may be accompanied by a discharge. Infections may spread to the uterus, fallopian tubes and ovaries and may become chronic. • Infertility can result if pelvic infection causes irreparable damage to the reproductive organs.

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Keloid scar. Slow and incomplete healing of the wound and post-operative infection can lead to the production of excess connective tissue in the scar. This may obstruct the vaginal orifice, leading to dysmenorrhoea (painful menstrual period). Following infibulation, scarring can be so extensive that it prevents penile penetration and may cause sexual and psychological problems. Abscess. Deep infection resulting from faulty healing or an embedded stitch can result in the formation of an abscess, which may require surgical incision. Cysts and abscesses on the vulva. Implantation dermoid cysts are the commonest complications of infibulation. They vary in size, sometimes reaching the size of a football and occasionally become infected. They are extremely painful and prevent sexual intercourse. Clitoral neuroma. A painful neuroma can develop as a consequence of trapping of the clitoral nerve in a stitch or in the scar tissue of the healed wound, leading to hypersensitivity and dyspareunia. Difficulties in menstruation can occur as a result of partial or total occlusion of the vaginal opening. These include dysmenorrhoea and haematocolpos (accumulation of menstrual blood in the vagina). Haematocolpos may appear as a bluish bulging membrane in the vaginal orifice and can prevent penetrative sexual intercourse. It can also cause distension of the abdomen which, together with the lack of menstrual flow, may give rise to suspicions of pregnancy, with potentially serious social implications. Calculus formation in the vagina can occur as a result of the accumulation of menstrual debris and urinary deposits in the vagina or the space behind the bridge of scar tissue formed after infibulation. Fistulae (holes or tunnels) between the bladder and the vagina (vesico-vaginal) and between the rectum and vaginal (recto-vaginal) can form as a result of injury during mutilation, defibulation or reinfibulation, sexual intercourse or obstructed labour. Urinary and faecal incontinence can be lifelong and may have serious social consequences.

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Development of a “false vagina” is possible in infibulated women if, during repeated sexual intercourse, the scar tissue fails to dilate sufficiently to allow normal penetration. Dyspareunia (painful sexual intercourse) is a consequence of many forms of female genital mutilation because of scarring, the reduced vaginal opening and complications such as infection. Vaginal penetration may be difficult or even impossible and re-cutting may be necessary. Vaginismus may result from injury to the vulval area and repeated vigorous sexual acts; the vaginal opening closes by reflex action causing considerable pain and soreness. Sexual dysfunction can result in both partners because of painful intercourse, difficulty in vaginal penetration, and reduced sexual sensitivity following clitoridectomy. Difficulties in providing gynaeclogical care. The scarring resulting from type III mutilation may reduce the vaginal opening to such an extent that an adequate gynaecological examination cannot be performed without cutting. For example, it may not be possible to insert a speculum to allow a cervical smear to be taken or to fit an intrauterine contraceptive device. Problems in pregnancy and childbirth are common, particularly following type III mutilation, because the tough scar tissue that forms causes partial or total occlusion of the vaginal opening and prevents dilation of the birth canal. Difficulty in undertaking an examination during labour can lead to incorrect monitoring of the stage of delivery and fetal presentation. Prolonged and obstructed labour can lead to tearing of the perineum, hemorrhage, fistula formation and uterine inertia, rupture or prolapse. These complications can lead to neonatal harm (including stillbirth) and maternal death. In the event of a miscarriage, the fetus may be retained in the uterus or birth canal. The infibulated woman must be defibulated to allow passage of the baby. Defibulation increase the risk of bleeding and may lead to damage to neighboring organs if performed incorrectly. There is also a risk of subsequent complications following re-infibulation. Where midwives and doctors are not familiar with defibulation procedures. Caesarian section may be performed.

SEXUAL, MENTAL AND SOCIAL CONSEQUENCES Female genital mutilation can have lifetime effects on the minds of those who experience it. Unfortunately, there is little systematic information on the sexual, mental and social effects of the practice on girls and women. Current information is based on field observations and preliminary pilot studies. 2. SEXUAL CONSEQUENCES Functions of the Female External Genitalia The clitoris is a key to the normal functioning, mental and physical development of female sexuality. Female infants discover arousal and pleasure associated with clitoral erection in their first year of life. Subsequent willful clitoral stimulation (mental or physical), plays a major role in the development of female sexuality. The clitoris and labia minora are supplied with a large number of sensory nerve receptors and fibers, with a particularly high concentration in the tip of the clitoris. These are connected to the brain, affecting sensory perception, which in return affects the muscle and secretory activities of the body, particularly the pelvic muscular and glandular activities. Clitoral erection releases chemicals in the brain (endorphins, dopamine and serotonin) that reduce pain and stress. Effects of Mutilation Many women who have undergone genital mutilation experience various forms and degrees of sexual malfunction. Genital mutilations that involve injury to or removal of the clitoris, particularly the clitoral up and the labia minora, result in damage to the concentrated nerve complex responsible for clitoral reaction, pelvic muscular and secretory activities, and for the transmission of sensory information to the central nervous system. Erection of a partially mutilated clitoris stretches scarred erectile tissue and stimulates damaged clitoral nerve tissues, which can be a painful and mental inhibiting ordeal. Loss or interruption of spontaneity of clitoral erection and damage to sensory perception impair arousal, which may inhibit sexual foreplay and affect the development of sexuality. Vaginal penetration, through damaged genital nerve and scar tissues, can be difficult or impossible without further tissue damage (tears) and bleeding. Orgasm is lost in many genitally mutilated women. Despite such sexual malfunctions, women with mutilated genitals seem to experience sexual desire and fantasy no less than women with intact genitals, and some degree of sexual enjoyment may be possible. This ability to compensate for lack of clitoris and other erogenous areas, and the emotional and physical propensity for the sexual act need to be further investigated to guide management of the sexual malfunctions of genitally mutilated women.

Male attitudes to sex and sexual pleasure in communities practicing female genital mutilation may reinforce the practice. For example, anecdotal reports suggest that in some communities practicing infibulation, achievement of difficult penetration of a tight vagina has become a proof of virility following marriage. 3. MENTAL AND SOCIAL CONSEQUENCES Genital mutilation is commonly performed when girls are quite young and uninformed and is often preceded by acts of deception, intimidation, coercion, and violence by trusted parents, relatives and friends. Girls are generally conscious when the painful operation is undertaken; no anaesthetic agent or other medication is used and they have to be physically restrained as they struggle. In some instances they are also made to watch the mutilation of other girls. For many girls, genital mutilation is a major experience of fear, submission, inhibition and suppression of feelings and thinking. This experience becomes a vivid landmark in their mental development, the memory of which persists throughout life. Older women have reported that nothing they have subsequently gone through, including pain and stress in pregnancy, childbirth, painful sexual intercourse and periods, has come close to the painful experience of genital mutilation. Some girls and women are unable or have difficulty recalling and describing the experience but their tension and tears reflect the magnitude of emotional pain they silently endure at all times. Although they may receive family support immediately following the procedure, girls may have feelings of anger, bitterness and betrayal at having been subjected to such pain. The resulting loss of confidence and trust in family and friends can affect the child-parent relationships and has implications for future intimate relationships with adults and with their own children. Other girls and women are expressive about the humiliation, submission and fear entrenched in their lives as a result of enduring the experience of genital mutilation. For many girls and women, the mental experience of genital mutilation and its mental aftermath, are very similar to those following rape. The experience of genital mutilation is commonly associated with psychosomatic and mental problems, symptoms and disorders which affect a wide range of brain functions. Girls have reported disturbances in eating, sleep, mood and cognition. These were manifested in sleeplessness, nightmares, appetites or weight loss or excessive gain, post traumatic stress, panic attacks, mood instability and difficulties in concentration and learning. As they grow older, women may develop feelings of incompleteness, loss of self-esteem, depression, chronic anxiety, phobia, panic or even psychotic disorders. These are compounded by the development of the serious long-term physical health effects of mutilation. Many women traumatized by their experience of genital mutilation have no acceptable means of expressing their fears and pains and suffer in silence. CONCLUSION Female genital mutilation is a deeply rooted traditional practice. It is a form of violence against girls and women that has serious physical and psychosocial consequences which adversely affect health. Furthermore, it is a reflection of discrimination against women and girls, as such should be condemned by all and sundry. Female genital mutilation WHAT IS FEMALE GENITAL MUTILATION? Female genital mutilation (FGM), often referred to as 'female circumcision', comprises all procedures involving 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. There are different types of female genital mutilation known to be practised today. They include: • • • • • •

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 - excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation); Type IV - 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 (angurya cuts) or cutting of the vagina (gishiri cuts); introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of tightening or narrowing it; and any other procedure that falls under the definition given above.

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 is infibulation, which constitutes about 15% of all procedures. HEALTH CONSEQUENCES OF FGM The immediate and long-term health consequences of female genital mutilation vary according to the type and severity of the procedure performed. Immediate complications include severe pain, shock, haemorrhage, urine retention, ulceration of the genital region and injury to adjacent tissue. Haemorrhage and infection can cause death. More recently, concern has arisen about possible transmission of the human immunodeficiency virus (HIV) due to the use of one instrument in multiple operations, but this has not been the subject of detailed research. Long-term consequences include cysts and abscesses, keloid scar formation, damage to the urethra resulting in urinary incontinence, dyspareunia (painful sexual intercourse) and sexual dysfunction and difficulties with childbirth. Psychosexual and psychological health: Genital mutilation may leave a lasting mark on the life and mind of the woman who has undergone it. In the longer term, women may suffer feelings of incompleteness, anxiety and depression. WHO PERFORMS FGM, AT WHAT AGE AND FOR WHAT REASONS? In cultures where it is an accepted norm, female genital mutilation is practiced by followers of all religious beliefs as well as animists and non believers. FGM is usually performed by a traditional practitioner with crude instruments and without anaesthetic. Among the more affluent in society it may be performed in a health care facility by qualified health personnel. WHO is opposed to medicalization of all the types of female genital mutilation. The age at which female genital mutilation is performed varies from area to area. It is performed on infants a few days old, female children and adolescents and, occasionally, on mature women. The reasons given by families for having FGM performed include: • • • • •

psychosexual reasons: reduction or elimination of the sensitive tissue of the outer genitalia, particularly the clitoris, in order to attenuate sexual desire in the female, maintain chastity and virginity before marriage and fidelity during marriage, and increase male sexual pleasure; sociological reasons: identification with the cultural heritage, initiation of girls into womanhood, social integration and the maintenance of social cohesion; hygiene and aesthetic reasons: the external female genitalia are considered dirty and unsightly and are to be removed to promote hygiene and provide aesthetic appeal; myths: enhancement of fertility and promotion of child survival; religious reasons: Some Muslim communities, however, practise FGM in the belief that it is demanded by the Islamic faith. The practice, however, predates Islam.

PREVALENCE AND DISTRIBUTION OF FGM Most of the girls and women who have undergone genital mutilation live in 28 African countries, although some live in Asia and the Middle East. They are also increasingly found in Europe, Australia, Canada and the USA, primarily among immigrants from these countries. Today, the number of girls and women who have been undergone female genital mutilation is estimated at between 100 and 140 million. It is estimated that each year, a further 2 million girls are at risk of undergoing FGM.

CURRENT WHO ACTIVITIES RELATED TO FGM •

Advocacy and policy development

A joint WHO/UNICEF/UNFPA policy statement on FGM and a Regional Plan to Accelerate the Elimination of FGM were published to promote policy development and action at the global, regional, and national level. Several countries where FGM is a traditional practice are now developing national plans of action based on the FGM prevention strategy proposed by WHO. •

Research and development

A major objective of WHO's work on FGM is to generate knowledge, test interventions to promote the elimination of FGM. Research protocols on FGM have been developed with a network of collaborating research institutions as well as biomedical and social science researchers with linkages to appropriate communities. WHO has reviewed programming approaches for the prevention of FGM in countries and has organized training for community workers to strengthen their effectiveness in promoting prevention of FGM at the grassroots level. •

Development of training materials and training for health care providers

WHO has developed training materials for integrating the prevention of FGM into nursing, midwifery and medical curricula as well as for in-service training of health workers. Evidence based training workshops, to raise the awareness of health workers and to solicit their active involvement as advocates against FGM, have also been developed for nurses and midwives in the African and Eastern Mediterranean region. Female Genital Mutilation Female Genital Mutilation (FGM) is a cultural practice that started in Africa approximately 2000 years ago. It is primarily a cultural practice, not a religious practice. But some religions do include FGM as part of their practices. This practice is so well ingrained into these cultures, it defines members of these cultures. In order to eliminate the practice one must eliminate the cultural belief that a girl will not become a women without this procedure. What is Female Genital Mutilation? Female Genital Mutilation is the term used for removal of all or just part of the external parts of the female genitalia. There are three varieties to this procedure. 1. Sunna Circumcision - consists of the removal of the prepuce(retractable fold of skin, or hood) and /or the tip of the clitoris. Sunna in Arabic means "tradition". 2. Clitoridectomy - consists of the removal of the entire clitoris (prepuce and glands) and the removal of the adjacent labia. 3. Infibulation(pharonic circumcision)-- consists of performing a clitoridectomy (removal of all or part of the labia minora, the labia majora). This is then stitched up allowing a small hole to remain open to allow for urine and menstrual blood to flow through. In Africa 85% of FGM cases consist of Clitoridectomy and 15% of cases consist of Infibulation. In some cases only the hood is removed. What is the age, the procedure used and the side effects? The age the procedure is carried out varies from just after birth to some time during the first pregnancy, but most cases occur between the ages of four and eight. Most times this procedure is done with out the care of medically trained people, due to poverty and lack of medical facilities. The use of anesthesia is rare. The girl is held down by older women to prevent the girl from moving around. The instruments used by the mid-wife will vary and could include any of the following items; broken glass, a tin lid, razor blades, knives, scissors

or any other sharp object. These items usually are not sterilized before or after usage. Once the genital area for removal is gone, the child is stitched up and her legs are bound for up to 40 days. This procedure can cause various side effects on the girls which can include death. Some of the results of this procedure are serious infections, HIV, abscesses and small benign tumors, hemorrhages, shock, clitoral cysts. The long term effects may also include kidney stones, sterility, sexual dysfunction, depression, various urinary tract infections, various gynecological and obstetric problems. In order to have sexual intercourse the women have to be opened up in some fashion and in some cases cutting is necessary. After child birth some women are re-infibulated to make them (tight) for their husbands. Is this practice a cultural or religious practice? In an FGM society, a girl can not be considered to be an adult until she has undergone this procedure. As well as in most cultures a women can not marry with out FGM. The type of procedure used will vary with certain conditions and these conditions could include the females ethic group, the country they live in, rural or urban areas, as well as their socioeconomic provenance. FGM is a culture identity practice. The fact that the procedure helps to define who is the group, is obvious in cultures that carry out this procedure as an initiation into womanhood. Most FGM societies feel that unless a girl has this procedure done she is not a woman as well as removal of these practices would lead to the demise of their culture. FGM societies have many claims of why this procedure should be done and these are as follows: 1. In most FGM societies one important belief is that this procedure will reduce a women's desire for sex and in doing so will reduce the chance of sex outside the marriage. This is vital to this society as her honor for the family is depended on her not to be opened up prior to marriage. 2. Some view the clitoris and the labia as male parts on a female body, thus removal of these parts enhances the femininity of the girl. 3. It is also believed that unless a female has undergone this procedure she is unclean and will not be allowed to handle food or water. 4. Some groups believe that if the clitoris touches a man's penis the man will die. As well as the belief that if a baby's head touches the clitoris that the baby will die or the breast milk will be poisonous. 5. The belief that an unmutilated female can not conceive, therefore the female should be militated in order to become fertile. 6. Bad genital odors can only be eliminated by removing the clitoris and labia minora. 7. Prevents vaginal cancer. 8. An unmodified clitoris can lead to masturbation or lesbianism. 9. Prevents nervousness from developing in girls and women. 10. Prevents the face from turning yellow. 11. Makes a women's face more beautiful. 12. Older men may not be able to match their wives sex drive. 13. Intact clitoris will generate sexual arousal and in women if repressed can cause nervousness. FGM does predate Islam, but most Muslims do not practice this. FGM was also practice by Falasha (Ethiopian Jews). The remaining FGM society's follow traditional Animist religions. To see a list of groups click here. In countries where Muslim's practices FGM, they can justify it, in the words of the Prophet Mohammed, in these two controversial sayings that are found in the Sunnah (words and actions of Mohammed) A discussion was recorded between Mohammed and Um Habibah (or Um'Alyyah), a women performed infibulation on slaves. She said that she would continue the procedure "unless it is forbidden and you order me to stop doing it". He replied (according to one translation) "Yes it is

allowed. Come closer so I can teach you: if you cut, do not over do it, because it brings more radiance to the face and it is more pleasant for the husband." Mohammed is recorded as speaking of the Sunna circumcision to Ansar's wives saying: "Cutting slightly with out exaggeration, because it is more pleasant for your husbands." These passages are regarded to have little credibility or authenticity with in the Muslim religion and is contradiction in the Qur'an: God apparently created the clitoris for the sole purpose of generating pleasure. It has no other purpose. There is no instructions in the Qur'an or in the writings of the Prophet Mohammed which require that the clitoris be surgically modified. Thus God must approve of its presence. And also, it should not be removed or reduced in size or function. the Qur'an promotes the concept of a wife being given pleasure by her husband during sexual intercourse. Mutilated genitalia reduces or eliminates a women's pleasure during the act. There is an estimated 135 million girls and women that have gone through this procedure with an additional 2 million a year at risk. This procedure is practiced in Africa (28 countries), Middle East, parts of Asia as well as in North America, Latin America, and as well as in Europe. It is now believed that the practice originated in Africa and is a cultural practice. Follow this link to see some indicators supporting this conclusion. Amnesty International now has taken up the fight to do away with this practice that mutilates millions of girls each year. Today FGM is seen as a human rights issue and is recognized at an international level. FGM was in the universal framework for protection of human rights that was tabled in the 1958 united Nation agenda. It was during the UN Decade for Women (1975-1985) that a UN Working Group on Traditional Practices Affecting the Health of Women and Children was created. This group helped to develop and aided to the development of the 1994 Plan of Action for the Elimination of Harmful Traditional Practices Affecting the Health of women and Children. the World Health Organization, the United Nations Children's' Fund and the Untied Nations Population Fund, unveiled a plan in April 1997 that would bring about a major decline in FGM within 10 years and the complete eradication of the practice within three generations. Nahld Toubia, MD, a physician from Sudan and assistant clinical professor in CSPH's center for Population and Family Health states: "Female circumcision is the physical marking of the marriage ability of women, because it symbolizes social control of their sexual pleasure-- clitoridectomy--and their reproduction-infibulation," Toubia also believes that female circumcision raises numerous human right issues, including reproductive rights, the protection from violence, women's rights and especially children’s rights since most circumcisions take place on girls who are four to ten years of age. Even though there is no theological basis for the practice of FGM, it will be hard to eradicate, until we have a better understanding of the cultural beliefs. Professor Stephen Isaacs, J.D, who specializes in human rights issues states "Human rights transcend cultural relativism by definition," and goes on to also state "But the cultural-religious argument has to be taken into consideration for implementation of policy." But with this Toubia maintains that the goal in ending FGM must never be compromised. "No ethical defense can be made for preserving a cultural practice that damages women's health and interferes with their sexuality," "It is only a matter of time before all forms of female circumcision in children will be made illegal in Western countries and, eventually, in Africa." Toubia states.

Female Genital Mutilation • • •

Types of Female Genital Mutilation Health Consequences of FGM Management o Clinical management o De-infibulation During Pregnancy and Labour

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Suturing Post De-infibulation Referrals De-infibulation - Gynaecology Legal Issues Support and Resources for Staff Supportive Material

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Flowcharts

Definition The World Health Organization (1997) defined Female Genital Mutilation (FGM) as "all procedures involving partial or total removal of the female external genitalia or other injury to the female genital organs whether for cultural or other non-therapeutic reasons." The United Nations identifies FGM as a form of human rights abuse on the female child and supports the eradication of this practice in countries where it is prevalent. Origins of Practice The act of Female Genital Mutilation predates both Christianity and Islam and does not pertain to any specific religion. The practice of infibulation is thought to have arisen out of ancient Egypt. It is also suggested that FGM was associated with patriarchal societies in which men needed assurance of family blood lines. Clitoridectomy, a less extreme form of FGM, was known to be used in Western medicine as late as the 1950's as a treatment for perceived "female psychiatric illnesses." Reasons for the Practice These are complex, arising from a belief system based on cultural and social tradition and impinge on the woman's social acceptance and marriageability within her community. While some people believe FGM to be part of religious requirements, this is in fact not the case. Prevalence of Practice The WHO (2000) estimates that as many as 100 and 140 million women and girls are affected world wide. This extrapolates to approximately 2 million girls per year at risk of being circumcised. Regions where various extremes of FGM are practiced include Africa, Asia, South America and the Middle East. Use of Terminology The term Female Genital Mutilation may cause offence to some who practice or have experienced the procedure. Its use in consultation may have the potential to be counterproductive to forming an effective professional relationship with the client and hence detrimental to the provision of her ongoing care for what is a sensitive issue. Accepted forms of description are traditional female surgery or cutting or female circumcision. For further information go to RWH FARREP website.

Types of Female Genital Mutilation The different types of FGM are classified by the extent of the surgery:

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Type 1: Excision of the prepuce, with or without excision of part or all of the clitoris.

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Type 11: Excision of the clitoris with part or total excision of the labia minora

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Type 111: Excision of part or all of the external genitalia and stitching/ narrowing of the vaginal opening (infundibulation)

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Type 1V: Unclassified, but includes: pricking, piercing or incising the clitoris and/ or labia, stretching of the clitoris and/ or labia, cauterization by burning of the clitoris and surrounding tissue, scraping of the tissue surrounding the vaginal orifice or cutting of the vagina, the introduction of corrosive substances or herbs into the vagina to initiate tightening, bleeding or narrowing of the vagina, as well as any other procedure which falls under the WHO definition of FGM.

Health Consequences of FGM There are a number of problems associated with FGM. In the short term:

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severe pain shock haemorrhage trauma infection urinary retention damage to adjacent tissues. Death can result from infection or haemorrhage.

In the long term:

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dysuria implantation cysts dyspareunia recurrent UTI's and vaginal infections dysmennorrhoea PID / infertility surgical reversal of scar tissue in order to achieve intercourse.

FGM may have long term effects on the psychosexual and psychological health of those who have undergone the procedure. In more recent times concern has been expressed about the possible transmission of human immunodeficiency virus (HIV) due to the use of one instrument for multiple FGM procedures, but as yet is not confirmed by research (WHO, 2000).

Management • • • •

Women from regions known to practice the procedure should be asked whether they have undergone female circumcision in their first antenatal appointment at the hospital. Staff should be aware that women affected by the practice may also be experiencing a range of psychosocial issues that have arisen from their experience of FGM and/or migration and resettlement. The aim needs to be holistic care that is culturally sensitive and non judgemental (RANZCOG, 1997). The gender provider wishes of the woman should be taken into account in regard to care and referral.

If the woman has been affected by FGM an appointment should be made for her to see a Medical Obstetric FGM Liaison Officer, who will discuss with the woman her options regarding de-infibulation during pregnancy or labour (refer to flowcharts).

Clinical Management: For details including deinfibulation and re-suturing diagrams and instructions go to FARREP Web site: Practice Guidelines.

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Click on Clinical Management.

De-infibulation During Pregnancy and Labour • • • • •

De-infibulation is a form of corrective surgery. The available options should be discussed with the woman early in the pregnancy to facilitate appropriate management. If required by a pregnant woman, the procedure is best performed in the antenatal period after 20 weeks gestation, to facilitate clinical care during pregnancy and labour. A number of women prefer de-infibulation during labour as part of the birth process as they then only have to experience a painful procedure once. The woman needs to decide what is the best option for her.

Suturing Post De-infibulation • • •

Following de-infibulation over-sewing of the raw margins of the anterior incision is required to prevent reinfibulation with poor approximation of wound edges. Any extension of the anterior incision above the urethra may be repaired at that time. A routine repair of a medio-lateral episiotomy or perineal tear is also frequently required post labour.

Referrals • • •

Referrals to appropriate healthcare providers should be offered to women, including referral to the FARREP worker. The RWH offers the de-infibulation procedure to both pregnant and non-pregnant consumers of our care. Contact may be made via FARREP, Women's Health Information Centre (WHIC) or the Outpatients Department.

De-infibulation - Gynaecology •

For women seeking de-infibulation at the RWH appointments should be made for them with one of the Medical Gynaecology FGM Liaison Officers.

Legal Issues • •

Staff are expected to be aware of specific legislation in the State of Victoria and elsewhere in Australia which makes it a criminal offence to perform FGM. Further information is available from FARRUP and the RWH Legal Counsel.

Support and Resources for Staff • • •

Support/advice can be gained from Family and Reproductive Rights (FARREP) worker, extension 2211 or a FGM Liaison Officer as necessary. FGM Liaison Officer details for Medical, Nursing and Allied health staff. Flowcharts Antenatal, Birth Suite, Postnatal, Gynaecology

Supportive Material •

RWH internet site: o Website: Female Genital Mutilation o CPG: Violence Against Women: Management and Referral Options.

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RWH: Female Genital Mutilation (FGM) Resource Manual for Health Professionals, o services provided at Royal Women's Hospital

o o

algorithms for antenatal clinics and labour ward practice guidelines

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Female Genital Mutilation. Information for Australian Health Professionals. The Royal Australian College of Obstetricians and Gynaecologists, 1997

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The Royal Australian and New Zealand College of Obstetricians and Gynaecologists www.ranzcog.edu.au/

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Mama and Nunu (Mother and Baby), Pregnancy Care for African Women: An Information Manual for Service Providers, Women's Health West, 60 Droop Street Footscray, 3011. Tel. 9689 9588.

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Better Health Channel. www.betterhealth.vic.gov.au

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Women's Health Information Centre, Royal Women's Hospital, Tel. (03) 9344 2007.

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Family and Reproductive Rights Education Program Worker (FARREP), Royal Women's Hospital, Tel. (03) 9344 2211.

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Victorian Government Web Site: Victorian Law Today: www.dms.dpc.vic.gov.au