What is FGM?

AIMS Journal, 2014 Vol 26, No 2

Siobán O'Brien Green highlights the serious issues surrounding female genital mutilation

Female genital mutilation (FGM) is the partial or total removal of the external female genitalia, or any practice that purposely alters or injures the female genital organs for non-medical reasons, as defined by the World Health Organization (WHO).

The practice is internationally recognised as a form of gender-based violence and a fundamental violation of the human rights of women and girls: it subjects them to extreme health risks and may have life-threatening consequences.¹

Evidence of FGM has been found dating back thousands of years and the practice pre-dates all world religions such as Christianity, Islam and Judaism. FGM is concentrated mainly in 29 countries located across Africa and the Middle East (see below for list of countries). It is also practised in other regions and tends to be more associated with ethnicity than with nationality. Reports from Europe and other areas of inward migration such as North America indicate that FGM may continue to be practised amongst immigrant communities. Statistical estimates from census data suggest that in England and Wales more than 65,000 women and girls have undergone FGM, whilst in the Republic of Ireland data suggest that more than 3,700 women and girls residing in Ireland are victims of the practice. Both of these figures are likely to be an underestimation of the current FGM prevalence statistics.² In 2013 UNICEF estimated that globally more than 125 million women and girls have undergone some form of FGM.³

As with many harmful traditional practices, FGM is carried out by communities to continue their heritage and sustain cultural norms and values - many believing that they are continuing a practice based on the best interests of their children. FGM often aims to control a woman's sexuality and preserve virginity until marriage, which may enhance a girl's marriageability, and is frequently seen as a rite of passage and a way to conform to cultural standards of femininity and beauty. FGM is most often performed on girls between five and 14 years old, but this can vary with ethnicity, ranging from when a baby girl is a few days old to when a girl or woman is pregnant with her first child. FGM is a manifestation of long-held and continuing gender inequalities in a society and is a deeply traumatic and harmful form of genderbased violence.⁴ However, it should be noted that FGM is usually carried out by women (sometimes traditional birth attendants) who receive both status and income by performing FGM on girls.

FGM has many harmful consequences, both short and long term, including but not limited to: death, haemorrhage, tetanus, pelvic inflammatory disease, scarring, dysmenorrhoea (painful periods), dyspareunia (painful intercourse) and increased possibility of HIV and Hepatitis transmission. FGM is also associated with increased risk of developing psychological problems such as PTSD, anxiety and depression.² A major WHO study in 28 obstetric centres in six African countries found an increased risk of complications in women with FGM I, II and III, (see definitions on page 15) such as: caesarean section, postpartum haemorrhage, extended maternal hospital stay, infant resuscitation, stillbirth or early neonatal death and low birth weight. FGM was estimated to lead to an extra one to two perinatal deaths per 100 births in the study.⁵

Working with women who have undergone FGM

For midwives, and other healthcare professionals, knowledge is imperative to provide the best possible care for women who have undergone FGM and to respond to women in a culturally competent manner. Any woman who is born in, or has a parent from, a country or region that practises FGM may have undergone FGM. All discussions of FGM must be sensitive, woman-centred and mindful of cultural issues, privacy and possible language difficulties. A professional interpreter may be required to facilitate communication and understanding. It is not appropriate to use a family member, such as a husband or child, as an interpreter. Women may not be familiar with the term FGM or may find it insulting, and may, instead, refer to being cut, closed or circumcised. It is important to question and respond in a professional, caring and sensitive way to develop a trusting and respectful relationship. Any medical interaction or appointment with a woman who has been subjected to FGM provides the opportunity for recognition, appropriate referral, care and support and possibly preventative work, all of which are vital to ensure that the practice of FGM is not perpetuated. A list of hospitals and clinics in the UK offering specialist FGM ser vices is available on the Forward UK website. These clinics can be contacted for advice and referrals. Fur ther information on treatment and child protection is available on the FGM National Clinical Group website.

Women may present with symptoms that they do not associate with FGM or in some cases women may not be aware that they have undergone FGM, if it occurred when they were a baby. However, early identification in pregnancy of a woman who has undergone FGM is essential to plan care for her pregnancy, birth, postnatal period and to prevent re-suturing (re-infibulation of Type III FGM) requests after bir th. Prompt assessment and examination is especially needed when a woman is pregnant, as FGM may have left scar tissue, adhesions and in many cases a direct barrier to vaginal delivery. It is also key to discuss FGM prior to the birth as this is often a period of heightened fear and anxiety for women with FGM and a good rapport with midwives can assist greatly in alleviating concerns. Information should also be offered to the woman's husband/partner including the health repercussions of FGM, support available and legislation where applicable. FGM is considered a form of child abuse and it should be dealt with through existing policies for child protection. Referrals to Social Workers may be required, especially if a woman with FGM gives birth to a girl.² Working with women who have undergone FGM is often traumatic and upsetting for midwives and healthcare professionals. Seek advice, assistance and support in relation to self-care if required whilst being mindful of women's privacy. Contact any of the specialist FGM services listed on the Forward UK website for professional support and more information.

Legislation and prevention

Legislation is one apparatus in the movement for global eradication of FGM and it can encourage and support communities to abandon the practice. However, legislation must work along with community empowerment and gender equality mechanisms and efforts to eliminate violence against women to achieve long-term, sustainable change. Good practices in combatting FGM tend to be collaborative, partnership based, involve members of FGM practicing communities (including faith leaders, men and boys), be inter and multidisciplinary and receive ongoing financial and government support. Legislation criminalising FGM exists in the United Kingdom and the Republic of Ireland, as well as in many other European and African countries. Many recent legislative developments have included the principle of extraterritoriality, whereby it is illegal to perform FGM on a resident of a country even if the FGM takes place in a different countr y or while a girl is on holiday.⁴ Prosecution in cases of FGM is of course desirable to ensure that FGM is taken seriously by police, courts, legislative systems and processes, but ultimately it represents a failure on the part of child protection mechanisms, frameworks and structures. Overall eradication of the practice, while sensitively caring for women who have undergone FGM and protecting girls at risk of FGM, must be the long-term vision and inform all policy and work related to FGM.

Conclusion

FGM is a serious global challenge to women's health, human rights and safe birth and is a grave form of gender-based violence. While today FGM is concentrated in 29 countries, mostly in Africa, both Europe and North America have had a history of responding to women's mental illness and what was considered unacceptable or overly sexualised behaviour by preforming clitoridectomies.⁶ Efforts to encourage community abandonment of this harmful traditional practice are underway through legislative and community and female empowerment approaches. Often this can involve finding alternative employment for circumcisers, focusing on the human rights aspects that FGM denies for women (such as bodily integrity, health and life) and mobilising men as fathers and future husbands to speak out against the tradition of FGM in their community. Solely emphasising the harmful health effects of FGM may have a reverse impact by promoting the medicalisation of FGM, a practice that UNICEF, WHO and the International Confederation of Midwives (ICM) strongly reject.³ Midwives play a crucial role in effective care and support of women who have undergone FGM and also can contribute to halting the inter-generational continuation of this harmful traditional practice. Ever yone has a role to play as a vocal, informed champion for change towards the eradication of FGM globally.

Siobán holds a Master of Social Science (Social Policy) and a BA in Social Policy and History of Art. She is currently responsible for policy and research at Comhlámh, the Irish association of development volunteers and workers. Siobán also teaches in the School of Applied Social Science at University College Dublin. She has researched, published and presented on FGM and gender-based violence in Ireland and Europe and is a co-author of Ireland's first handbook for healthcare professionals on FGM. Contact her on sioban.obriengreen@ucd.ie

References

1. World Health Organization (2008) Eliminating female genital mutilation: An interagency statement. UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCHR, UNHCR, UNICEF, UNIFEM, WHO. Geneva: WHO.
2. O'Brien Green S, Patel S, Scharfe Nugent A, et al (2013) Female Genital Mutilation: Information for Health-Care Professionals Working in Ireland, Second Edition. Dublin: AkiDwA, Royal College of Surgeons in Ireland, Health Service Executive.
3. UNICEF (2013) Female Genital Mutilation/Cutting: A statistical overview and exploration of the dynamics of change. New York: UNICEF.
4. European Institute for Gender Equality (2013) Female genital mutilation in the European Union and Croatia - Report. Vilnius: EIGE.
5. World Health Organization. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. The Lancet 2006; 1835:367.
6. The FGM National Clinical Group www.fgmnationalgroup.org

Further reading

• RCM, RCN, RCOG, Equality Now, UNITE (2013) Tackling FGM in the UK: Intercollegiate Recommendations for identifying, recording, and reporting. London: Royal College of Midwives.