According to the World Health Organization, female genital mutilation “comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for nonmedical reasons” . Most of these female genital cutting procedures are performed for ritual and prophylactic purposes—often integrated into initiation ceremonies for cohorts of young women and girls. Although local logics vary across cultural groups, common reasons for the practices include the alleged reduction of female desire (and thus, reducing hypersexuality and promiscuity); the “cleansing” of girls and women; and ritual circumcision (analogous in meaning to procedures performed on boys and men) . The extent of the anatomical damage incurred through the procedures varies, and loosely correlates with the WHO’s classification of four types of cutting (Table 3). The cases presented here are all unusual manifestations of type 4 cutting, which are often less severely mutilating than the others, and differ from typical presentations of female genital mutilation in important ways. First, although female genital cutting is typically considered prophylactic and often practiced widely at the community level, the genital cuttings seen in this study were all performed therapeutically for individual cases of perceived gynecological or behavioral disorders. Indeed, these differing approaches to genital cutting are reflected in Mali’s 89% prevalence rate of female genital cutting among women aged 15 to 49 (mostly type 1 and type 2), whereas in Niger, the comparable rate is only 2% .
Despite the recognized risks of all forms of female genital cutting, which include sepsis, scarring, dyspareunia, infertility, psychological problems, hemorrhage, and sometimes death, within the understanding of traditional ethnomedical systems, these procedures are performed for what appear locally to be legitimate therapeutic purposes. Although there is no basis in biomedicine for the underlying assumptions that guide these practices, these systems of belief may nevertheless play a powerful role in directing the quest for therapy undertaken by patients and their families in parts of the world where traditional medical practices coexist with biomedicine in a pluralistic healthcare system . These cultural patterns of female genital cutting are often found in parts of the world where access to emergency obstetric care is poor and obstetric fistulas from obstructed labor are common .
For example, among the Hausa of northern Nigeria, there is a cultural belief in a gynecological condition called gishiri. Gishiri is the Hausa word for “salt,” and it refers to the common salt used in cooking, and to the chemical salts deposited at the bottoms of water jars as their contents evaporate. Gishiri (“salt”) plays a role in the traditional Hausa system of ethnomedicine, where it exists in balance with sweetness (zaki) and other humoral elements [15, 16]. The accumulation of “salt” in the vagina is thought to cause various ill-defined gynecological complaints, including dyspareunia, lack of interest in sexual activity, vaginal narrowing, and obstruction to birth during the second stage of labor. In such cases, the patient may be taken by family members to a barber (wanzami) or midwife (unguzoma), who performs a vaginal cutting procedure to eliminate the postulated condition. Usually, this involves incision of the anterior vagina and often results in accidental urethral injury. Case series of genito-urinary fistulas from northern Nigeria show gishiri cuts to account for between 1 and 18% of genito-urinary fistulas in this part of the world [5, 17,18,19,20]. In one analysis of the contribution of gishiri cutting to fistulas in northern Nigeria, the authors indicated that it has been performed for obstructed labor, to excise a perceived abnormal vaginal mass, and as a treatment for dyspareunia . In one case, the patient exsanguinated as a result and died from hemorrhagic shock. In Tahzib’s series of 80 cases of fistula in adolescent girls aged 13 or younger, the procedure was performed for dyspareunia, amenorrhea, coital difficulties, abdominal pain, vulvar rashes, general ill health, fevers, and infertility . He described these gishiri fistulas as “typically long and clean, mid-vaginal, with total or partial destruction of the urethra” , a description consistent with our findings in this series of cases.
Although the concept of gishiri does not travel across the Nigeria–Niger border, among the Hausa of southern Niger, a similar belief is called gurya (sometimes angurya or ‘dan gurya), a word generally translated as “cottonseed.” Here, the belief is that a girl may be born with a tiny “seed” within her genitalia that can expand or grow over time, eventually causing various problems affecting her physiology and disposition, such as lack of sexual desire or diminished vaginal capacity, which results in dyspareunia or even the inability to have vaginal intercourse at all. If gurya is diagnosed, the treatment, as with gishiri, is often a cutting procedure performed by a local barber.
Examination of the social circumstances of these 10 gurya cases reveals a very clear and disturbing pattern. For the most part, these patients with cutting-related fistulas were young women, all married as adolescents (range 12 to 16 years) who experienced repeated sexual trauma in the form of unwanted intercourse, with resulting marital disharmony, mental distress, and social discord. The early age of marriage is typical for this part of Africa, a social practice that often leads to pregnancy before pelvic growth is complete, predisposing many young brides to the development of obstructed labor and obstetric fistula formation (a common scenario in most series of obstetric fistulas [4,5,6]. However, none of the cases in this series was of obstetric origin and none appears to have been done as a rite of passage or a mandated cultural practice analogous to male circumcision, as is often true in many parts of Africa .
In contrast, these injuries appear to have resulted from cutting procedures that were intended to “open” the female genitalia so that the affected women would assume their culturally expected behaviors as willing (or at least tolerant) sexual partners for their husbands. In young adolescents who are married early, the vagina may not yet be sufficiently developed to allow atraumatic sexual intercourse, a fact that itself may lead to fistula formation . In adolescent girls, especially those who are married without their consent, early unwanted intercourse may be both physically and emotionally traumatic, leading to anticipatory pain and guarding, which only serve to make subsequent sexual encounters more traumatic, starting a vicious psycho-sexual spiral from which they may never escape. A genital cutting procedure can only make this worse. Clinical interviews with many of the women in this series revealed the presence of co-existent anxiety and depression and in some cases post-traumatic stress disorder was suspected. Given their circumstances, this should not be surprising.
The underlying cultural assumption among the Hausa is that the proper role of women is to be wives. As wives, they should be submissive to their husband, seeking to please him both socially and sexually, and to provide him with many children as his “return on investment” from the marriage payments. Indeed, Hausa men regard women as “fields” to be “tilled” sexually, and the children that result are the “crop” or “profit” from such “tilling.” If the “field” does not wish to be “tilled” or finds the “tilling” to be unpleasant or painful, there must be something wrong with her—certainly psychosocially if not also biologically. There are also cases of women with gurya in whom the diagnosis was made after years of unsuccessful attempts at consensual vaginal penetration following marriage . It was only after “therapeutic” cuttings produced genitourinary fistulas that caused their referral to hospitals that these women were diagnosed as having congenital abnormalities of the genitourinary tract. Indeed, gurya appears to be a diagnosis that is given to a wide range of female disorders in Nigerien Hausa society.
The fistula cases from genital cutting in this series are not the result of obstetrical trauma or a cultural rite of passage; rather, they are reflective of a society in which women are regarded primarily as sexual objects and incubators for children, rather than persons worthy in their own right, irrespective of their sexual attractiveness or personal characteristics. These fistulas are the result of a misguided therapeutic intent on the part of local traditional medical practitioners. All the injuries described in this paper were preventable, but any effective prevention strategy must pursue two complementary arms simultaneously: elevating the status of women in this part of the world, and at the same time providing them with access to competent, culturally acceptable obstetrical and gynecological care so that the need to access local cutting therapies of the type discussed here is no longer seen as necessary.