Relevant Aspects of Female Genital Mutilation

Abstract

This chapter deals with FGM, female genital mutilation, also named female genital cutting or female circumcision. Though mainly practised in African and Middle East countries, it is still the reality for many women and girls who migrated from those countries to Europe and other parts of the world. In 2022, UNICEF estimated that, globally, at least 200 million women and girls had undergone this procedure.

The physical damage and consequences of FGM depend on the extent of the procedure and the medical and hygienic conditions during the event. Circumcised women deserve proper care regarding their medical and obstetrical side effects. This chapter will address some of the expected urological, gynaecological, and obstetrical consequences for the midwife who meets women with FGM throughout pregnancy, childbirth, and postpartum. On the other hand, this chapter will address various aspects of FGM’s psychological, sexual, and social impact on the woman and the couple.

It can be confusing for the midwife who doesn’t work (or doesn’t yet work) in a multicultural setting when confronted with women after FGM. So the chapter will elaborate on ‘How to approach the woman after FGM in a respectful and caring manner?’

This chapter is part of ‘Midwifery and Sexuality’, a Springer Nature open-access textbook for midwives and related healthcare professionals.

1 Introduction

Female genital mutilation (FGM), also called female genital cutting (FGM/C) or female circumcision, is a widely practised phenomenon or tradition in many African countries, some countries in the Middle East, and Indonesia. It is defined as ‘an intervention on the external female genitalia without medical necessity’.

There is a wide variety in the extent of the intervention, how the intervention takes place, the short and long-term consequences for physical and reproductive health, and the psychological and sexual consequences.

This chapter will give information about FGM so that the HCP can provide optimal guidance to women without compromising their experience or their culture.

The chapter will start with a brief description of the phenomenon with backgrounds and explanations and some figures on prevalence. Then some details of the circumstances and the extent of the procedure will be given, followed successively by the various consequences of FGM: first, the direct results of the intervention, and then the long-term physical, obstetric, psychological, and sexual consequences. The last part will discuss aspects of dealing with clients with FGM.

2 A Brief Description of the Phenomenon with Backgrounds and Explanations

The origin of FGM is unclear. In Islamic Africa, it is frequently explained as a religious commitment, assuming that Prophet Mohammed mentioned in one of his Hadiths that ‘having undergone Sunna (FGM type 1) is a symbol of cleanliness and purity for a girl’.

The reality is that FGM is a pre-Christian and pre-Islamic practice.

FGM is deeply rooted in cultural traditions that differ by family, region, and country. Among the arguments to continue with FGM are:

• The clitoris is supposed to be dangerous (‘the devil’) or hazardous for the man’s orgasm.

• A girl without a clitoris is supposed to have no sexual desire, so it is more likely that she will keep her virginity till marriage.

• Without a clitoris, the married woman is neither supposed to have nor show sexual desire. The man should show desire.

• The procedure is regarded as providing beauty, purity, and cleanliness.

• In some countries, circumcision is said to promote fertility and increase male sexual pleasure.

• Circumcision is an initiation rite into womanhood. In some areas, ‘not being circumcised’ is experienced as being incomplete and lacking social status (or even running the risk of being expelled). Circumcision is then usually considered a ‘festive’ rite of passage [1].

On the other hand, the WHO very clearly states that FGM violates the human rights of girls and women and that the practice of FGM has no health benefits for them [2]. ICM, the International Confederation of Midwives, recognises and condemns FGM as a harmful practice and a violation of the Human Rights of girls and women [3].

The tradition of FGM reflects the deep-rooted inequality between the sexes and constitutes an extreme form of discrimination against women. It violates a person’s rights to health, security, and physical integrity, the right to be free from torture and cruel, inhuman, or degrading treatment.

3 Prevalence and Where Can It Be Found

According to UNICEF, more than 200 million women and girls alive today have been cut [4]. They are mainly living in the 30 countries where FGM is commonly practised [4]. The prevalence in those countries varies and is usually given for the 15–49 age group. In part of these countries, the prevalence is decreasing. However, according to UNICEF, the absolute global figures are still growing because of the increasing population.

Egypt is a clear example of that trend. In women aged 15–49 years., the prevalence of FGM decreased from 97% to 70% between 1985 and 2015. The population increase of 85% over this period caused a 35% increase in the absolute amount of FGM.

In a 2013 report by UNICEF, Egypt had the highest absolute number of FGM, whereas Somalia had, with 98%, the highest global prevalence.

Starting in the 1970s, when more migration from Africa and the Middle East got underway, the Western medical world became confronted with women who had FGM. So it gradually became a topic of public discussion.

4 Details of the Circumstances and the Extent of the Procedure

FGM is usually performed in childhood. Depending on the different (sub-)cultures, there is much variety in the preferred age. In Yemen, the vast majority occurs in the first week after birth, whereas in Egypt, one quarter occurs at ages 5–9 and 70% at ages 10–14. In the more rural areas of many countries, the procedure was (and regularly still is) traditionally performed without anaesthesia and septic precautions. Frequently, the mother plays a prominent role, e.g. holding her daughter down and keeping her eyes closed.

In many cultures, FGM is a rite of passage and a nearly inescapable major life event, surrounded by festivities. Over many years the girl is, in a way, seduced by various promises. The circumcision is ‘the path to make her perfect, with absolute beauty and purity as a woman’.

Despite being aware of the pain, the fear, and the other side effects, they have suffered themselves, most mothers and grandmothers continue to adhere to this tradition.

The extent of the procedure is the basis of the four types of FGM that the WHO distinguishes. Because the clitoris has such an essential role in the FGM arguments and the FGM procedures, it deserves some extra attention. The clitoris is far bigger than the tiny, highly sensitive spot frowned upon in many FGM cultures (see Fig. 25.1). Next to the glans, shaft, and hood (the foreskin), the clitoris has two crura and two spongious bodies that swell when aroused. In none of the FGM procedures, the crura and the spongious bodies are removed. These remaining parts are responsible for the fact that many women, despite FGM, can experience orgasm [5].

Fig. 25.1

The Clitoris. (Illustration composed by Gabrijela Simetinger and Helena Černej)

4.1 The WHO Classification of FGM

Female genital mutilation is classified by the WHO into four major types [2]. See Fig. 25.2.

• Type 1: This is the partial or total removal of the clitoral glans (the external and visible part of the clitoris, which is the most 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 lips), with or without removal of the labia majora (the outer lips).

• 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 inner lips, or outer lips, sometimes through stitching, with or without removal of the clitoral prepuce/clitoral hood and glans.

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

Fig. 25.2

The WHO classification of female genital mutilation. (Redrawn by WL Gianotten)

In the Pharaonic type (Type 3) with infibulation, the small opening for urine and blood is told to be not wider than a grain of rice or the head of a match.

Geographically, there are many differences in the prevalence of the various types. In Somalia and Sudan, close to 98% of girls undergo the Pharaonic type, although, in the last decade, a small percentage of mothers have chosen Sunna (Type 1) for their daughters. In Sunna, the specialised woman takes the clitoris between two fingers and pulls the prepuce very strongly till it tears and starts bleeding (the blood ensures the girl’s purity).

Another change is that the procedure is shifting to the medical field. In Egypt, for instance, 60% of girls have undergone the procedure by a physician and 10% by another HCP.

Instead of relying on geographical prevalence figures, it is better to ask what kind of circumcision the woman has had and by whom.

At the time of marriage, the nearly closed vagina has to be reopened. In Sudan and Southern Somalia, traditional defibulation has to be done by the bridegroom through penile penetration. He has to put sufficient pressure on the infibulation seal, causing it to tear, which is painful for both partners. The time needed for defibulation varies depending on the amount of force and the thickness of the scarred seal. Generally, it is supposed to be accomplished within a week [6].

In other areas, like northern Somalia, the infibulation is cut open by an excisor (circumciser). In both cases, the couple has to continue penetration for several weeks to prevent the vagina from reclosing. This ‘maintenance’ is painful because of the open wounds, and many women experience this defibulation period as painful as the original infibulation. Infections and bleeding are common [6].

5 The Consequences of the Intervention

In the broader sense, FGM is a severe violation of the rights of girls and women, strongly impairing the process of normal development. In the context of this chapter, it can be seen as a complicated and painful process causing damage to physical and mental health and sexuality. The amount of damage depends on many factors.

• The age at which FGM is performed,

• The extent of the procedure and the skills of the person who performs the procedure,

• The practicalities (duration of the operation, hygiene, et cetera),

• The resilience, resistance, and physical power of the girl/woman,

• The balance between emotional support and force,

• Living inside or outside an FGM-endemic society,

• The level of sexuality education and the approach to sexuality.

Many reported data are not very reliable. Partly because of a lack of appropriate comparison groups. And frequently also started from a biased underlying frame of reference [7].

Here a distinction is made between physical (‘medical’), reproductive, mental (‘emotional’), and sexual consequences.

5.1 Physical Disturbances

Among the immediate health complications are:

• Severe pain (especially when performed without anaesthesia).

• Blood loss with haemorrhagic shock.

• Local oedema causing impaired urination and defecation.

• Injury to the urethra, vagina, or rectum.

• Death due to blood loss and infections (including tetanus).

Among the late medical complications are

• Chronic pain from trapped or unprotected nerve endings.

• Dermoid cysts, abscesses, and genital ulcers with superficial loss of tissue.

• Excessive scar formation by keloid. Keloid is extensive scar tissue, common in people with Sub-Saharan African genes.

• Chronic pelvic infections causing chronic backache and pelvic pain.

• Urinary incontinence and dribbling of urine (especially after infibulation), owing to difficulties emptying the bladder and stagnation of urine under the hood of scar tissue. Recurrent urinary tract infections and damage to the kidneys with eventual renal failure.

• Infection with HIV.

5.2 Reproductive and Obstetric Disturbances

Especially infibulation, but also the defibulation phase can cause reproductive disturbances.

• Painful menstruation due to the near-complete sealing of the vagina and urethra.

• Endometriosis due to retained menstrual blood.

• Vesicovaginal and rectovaginal fistula (after obstructed labour).

• A narrowed obstetrical birthing channel.

• Perineal tears.

• Postpartum haemorrhage.

• Associated neonatal morbidity.

Whereas traditional defibulation usually creates enough room for sexual penetration, that room is not enough for smooth childbirth. The vaginal outlet can need medical widening during childbirth (‘medical defibulation’). In a study from Saudi Arabia, defibulation at birth was performed as a surgical procedure [8]. In that study, the women defibulated at birth had fewer instrumental deliveries and less blood loss (with no differences in the neonatal outcome). The authors concluded that HCPs working with women with FGM type-3 should learn how to perform this medical defibulation [8].

5.3 Mental/Emotional Health Issues

The FGM procedure can be an extremely psychotraumatic event depending on various factors. The girls’ age at the procedure is a relevant factor. The older the girl, the more likely she will have anxious anticipation, and the more she will be confused (aware that she has to agree without real consenting). During the procedure itself, the pain, the shock, and the amount of physical force by those performing the cutting are relevant elements. That is especially when she feels betrayed (for instance, when the mother forces the girl to surrender). At a later stage, additional damage can develop due to the fear of pain when getting married. And also after marrying due to the pain in the trajectory of defibulation by the husband.

Migrating to a more woman-friendly society without FGM and with apparently more social and sexual freedom creates opportunities for comparison. Whereas in the original culture, ‘not being circumcised’ can have caused feelings of incompleteness and inferiority, the same feelings can develop after migrating, but now precisely because of having been circumcised [9].

Among the consequences are found:

• Post-traumatic stress disorder (found in 1 in 6 migrant women in the Netherlands) and depression or anxiety (1 in 3) [10].

• Psychiatric and psychosomatic disturbances.

• Lowered self-image, with the feeling of incompleteness and inferiority.

• Chronic irritability, sleep problems, and nightmares.

5.4 Sexual Issues

Sexuality after FGM appears an ultimate example of the complex choreography between various bio-psycho-socio-cultural influences. Even with removing the glans, shaft, and hood of the clitoris, there is sufficient remaining erectile clitoral tissue [5]. However, for an orgasm, more is needed than only anatomy. One needs enough and adequate stimulation, which is influenced by the presence and amount of pain, the fear of pain, the erotic support of the partner, and the amount of sexuality-positive education the woman has received.

Infibulation can easily plunge the woman into a vicious circle of pain, fear of pain, low arousal, dry vagina, and high pelvic floor tone. A meta-analysis compared the sexual function of women with and women without FGM. Women with FGM scored worse in all domains (desire, arousal, lubrication, orgasm, satisfaction, and pain) [11]. That can also develop during and in the period after defibulation, resulting in low or no sexual pleasure, potentially leading to relational problems and even divorce.

However, for some other couples, that strenuous defibulation period can also forge a close bond between the partners.

In dealing with FGM, caution appears needed when assessing research questions and results. That was, for instance, clear in Egyptian research [12]. Whereas FGM is supposed/intended to reduce a woman’s sexual appetite and increase her chastity, it was not believed to reduce her sexual pleasure. However, sexual pleasure was framed differently by men and women. While (especially younger) men considered sexual satisfaction a cornerstone of marital happiness, women considered themselves sexually satisfied with marital harmony and a satisfactory socio-economic situation.

Acculturation to Western culture can create the request to defibulate, either to get rid of pain or to obtain more sexual pleasure. Proper surgical anatomy reconstruction usually gives patients and husbands high satisfaction [14].

On the other hand, Western HCPs can get confused by women requesting to re-infibulate after childbirth (in other words: narrowing the entrance). Vaginal tightness can be considered a prerequisite for male sexual pleasure and can be intimately linked to infibulation [6].

6 Dealing with FGM

In 2015 the global community clearly stated that FGM violates human rights. The Sustainable Development Goals (SDGs) have laid this down under Goal 5. The target is, by the year 2030, to eliminate all harmful practices, such as child marriage, early marriage, forced marriage, and FGM/C,

That has clear consequences for HCPs in countries where FGM is endemic. They should proactively clarify not to agree with these procedures. On the one hand, by participating in public health education about FGM and its harmful consequences. On the other hand, even more important, by not performing these procedures themselves. In several countries, FGM has become strongly medicalised and an important source of income. The International Confederation of Midwives clearly states that midwives should refrain from supporting or participating in any form of the practice at any time and that they have to respect relevant (inter)national codes of ethics [3].

Gynaecological and obstetric HCPs with, in their community, migrants from FGM societies have to be prepared to deal with the consequences of FGM. They have to acquire the skills to defibulate during labour or when women request defibulation to relieve pain or improve their sexual life.¹

Part of comprehensive care is proper health education for the women of those migrant communities. Having migrated to the Western world is no guarantee that FGM will be abandoned. Up to one-third of North African girls living in Scandinavia were found to be circumcised when visiting their home country [15].

Another aspect of good care is how to deal respectfully with this other reality. Whereas the term mutilation is used in this chapter, using that term with the woman in question can be experienced as offensive and degrading. Then the term circumcision is preferable.

When confronted with FGM, HCPs need to be aware that their response impacts the women. Looks—sometimes spontaneous and unaware—of astonishment or even horror can also damage women’s mental health. Many women have felt ashamed of a physical examination and avoided HCPs who did not conceal their astonishment about FGM or how it looked [8].