Abstract
In the United Kingdom, up to 20,000 young women and children who originate from the horn of Africa, Senegal and various parts of sub-Saharan Africa are potentially at risk of being subjected to this criminal and barbaric ritual. This is despite the efforts of FORWARD and Baroness Ruth Rendell, the writer and human right's campaigner.
There have now been two Acts of Parliament in the United Kingdom, the first act in 1995 (the Prohibition of Female Circumcision Act) and the latest being the Female Genital Mutilation Act of 2003. However we believe that women in this ethnic group, some as young as 4 years old, remain at risk.
It is also difficult to find out if these procedures still take place in the UK. Most young girls are taken out of the country to have the ritual carried out. The new Act of 2003 was set up to protect them from leaving the country.
The medical profession, social services, teachers and the child protection agencies need to work more closely to protect these individuals.
Worldwide 2 million young women remain at risk of being subjected to this ritual every year.
‘Mama tied a blindfold over my eyes. The next thing I felt my flesh was being cut away. I heard the blade sawing back and forth through my skin. The pain between my legs was so intense I wished I would die.’ (Dirie, UNFPA Goodwill Ambassador and spokesperson on female genital mutilation)
Female genital mutilation worldwide
Female genital mutilation (FGM), also known as female circumcision or female genital cutting, is defined by the World Health Organization (WHO) as the range of procedures which involve ‘the partial or complete removal of the external female genitalia or other injury to the female genital organs, whether for cultural or any other non-therapeutic reason’.
There is now evidence that approximately 138 million African women have undergone FGM worldwide and each year a further two million girls are believed to be at risk of being subjected to the practice. The majority of these young girls live in African countries, a minority in the Middle East and Asian countries. We are now seeing an increasing number in Europe, Australia, New Zealand, the United States of America and Canada. 1
How is the procedure carried out?
An untrained older woman with no medical knowledge traditionally carries out the procedure. We have learnt from victims of FGM that these rituals are carried out without either anaesthetics or antiseptics. The practice is usually carried out using basic tools such as knives, scissors, scalpels, pieces of glass and razor blades. Often iodine or a mixture of herbs is placed on the wound to tighten the vagina and stop the bleeding.
The age at which the practice is carried out does vary, from between shortly after birth to the labour of the first child, depending on the community or individual family. The most common age is between four and 10 years of age, although it appears to be falling. In the Sudanese tradition a mother is re-circumcised following the birth of a child. This has been outlawed by the Act of 2003.
There is naturally significant psychological and medical pathology associated with the procedure. The mortality is considered to be as high as 10%. This is caused by both primary haemorrhage (bleeding at the time of the ritual) to sepsis from infected instruments. There is also significant morbidity from chronic bladder infections leading to chronic renal failure as a result of a prolonged micturition cycle. We have evidence 2 that these rituals have now been modified in Somalia, and in our most recent study, less than 20% of women had absent or damaged labia.
In this study, 2 we had expected to find psychosexual problems in women with FGM, however we had only two spontaneous complaints (both in women born in the UK and infibulated abroad). We found the women reluctant to discuss sexual matters outside the family, and we were not able to produce any new evidence. We even employed a female psychotherapist to set up workshops to determine the extent of their psychological trauma. Our impression was that because virtually 100% of Somali women are subjected to FGM in childhood, this becomes ‘part of being a woman’.
There is some documentation of sexual issues in Sweden. 3 This tended to confirm the work of Okonofua, 4 who found that FGM 2 with its associated clitoridectomy did not reduce sexual activity, nor prevent orgasm. However this group had not undergone FGM 3 (Table 1).
WHO classification of genital mutilation
Type 1 involves the excision of the prepuce with or without excision of part or the entire clitoris. It is seen in Egypt.
In type 2, there is excision of the prepuce and clitoris, together with partial or total excision of the labia minora.
Type 3 is most commonly seen in the Somali population. This is very barbaric, and includes excision of part or all of the external genitalia and stitching or narrowing of the vaginal opening, also known as infibulation. This is the most extreme form, and constitutes 15% of all cases. It involves the use of thorns, silk or catgut to stitch the two sides of the vulva. A bridge of scar tissue then forms over the vagina, which leaves only a small opening (from the size of a matchstick head) for the passage of urine and menstrual blood. These are often the ‘tell-tale’ signs for teachers, practice nurses and general practitioners.
Type 4 includes pricking, piercing or incision of the clitoris and/or the labia; stretching of the clitoris and/or the labia; cauterization or burning of the clitoris and surrounding tissues, scraping of the vaginal orifice, or cutting (Gishiri cuts) of the vagina and introduction of corrosive substances or herbs into the vagina. This is common in some parts of sub-Saharan Africa.
The clinical consequences of FGM
Death from infection and haemorrhage Chronic renal infection; urethral scarring Emotional trauma and flashbacks Incontinence Traumatic childbirth (physical and emotional) Infertility Chronic vaginal infection
Historical background
It is uncertain when FGM was first practised, but it certainly preceded the founding of both Christianity and Islam. There is no basis for the belief that the procedure was advocated or approved by Mohammed, nor is it in any way part of the Islamic faith. Though the operation is largely confined to Muslims, it is also performed in certain Christian communities in Africa (Ghana, Nigeria).
Cultural beliefs
In the least destructive ritual, when only the prepuce of the clitoris is removed, the object is to reduce the woman's sexual desire, and hence to ensure her virginity until she is married. The more extensive rituals, involving stitching of the vagina, have the same aim of ensuring chastity until marriage. The reduction in the size of the vaginal orifice is supposed to increase the husband's enjoyment of the sexual act; there is no good evidence for this and initially penetration may be difficult and painful for both partners. From our work, it is clear that anal intercourse remains the most common form of sexual intercourse.
Another view is the ritual ensures a satisfactory bride price; an eligible man would not consider marrying a girl who had not had been circumcised. The procedure is arranged by the mother or grandmother, and in Africa is usually performed by a traditional birth attendant, a midwife making a little extra money, or by a professional exciser. FGM is supported and encouraged by men; indeed the operation can be regarded as an exercise in male supremacy and the oppression of women.
Finally, it is believed that evil will happen if the clitoris touches the baby's head during childbirth.
FGM in Western society
Female ‘circumcision’ was practised by the European and American medical professions in the 19th century 5 as a cure for a wide variety of conditions including insomnia, sterility, unhappy marriage and psychological disorders. It was advocated by no less a figure than the father of gynaecology, J Marion Sima. Jonathan Hutchinson, then president of the Royal College of Surgeons, enthusiastically advocated circumcision and ‘other measures more radical than circumcision’ to prevent the adverse mental effects of masturbation as ‘a true kindness to many patients of both sexes’.
The last known medical female circumcision in the richer world took place in Kentucky in 1953, on a 12-year-old girl. 5 Our own sexually repressive use of FGM may be at the root of our misunderstanding of its role in other cultures.
Cultural aspects of medical care for Muslim women
Another cultural issue relates to requests to see only female attendants on religious grounds. In fact, this is clearly not an absolute requirement. In many devout Islamic countries (e.g. Saudi Arabia), almost all gynaecologists are male. The religious duty can be summarized as follows:
If possible, a Muslim female should see a female doctor. However, if none is available, or if a male doctor has more experience, it is her religious duty to see the man. It is an Islamic principle that she has a religious duty to look after her health.
Legal perspective
Female genital mutilation was made illegal in Britain by the Prohibition of Female Circumcision Act 1985. Under this act it became an offence to ‘excise, infibulate, or otherwise mutilate the whole or any part of the labia majora or labia minora or clitoris of another person’ or ‘to aid, abet, or procure the performance by another person of any of these acts on that other person's own body’.
A person found guilty of an offence was liable to a fine or to imprisonment for up to five years, or both, if convicted on indictment before a judge and jury in a crown court, or on summary conviction in a magistrate's court to a fine or imprisonment for up to six months, or to both.
In Britain no prosecutions have been obtained under the Act but convictions have been obtained in France. In 1993 a medical practitioner was brought before the General Medical Council charged with performing female circumcisions while knowing that the operation was illegal; he was struck off. Legislation prohibiting FGM has also been passed in Sweden and Belgium and in some states in America.
In 1959 the general assembly of the United Nations adopted the Convention on the Rights of the Child, which states (article 24, paragraph 3) that ‘Parties shall take all effective and appropriate measures to abolish traditional practices prejudicial to the health of children’.
In 1982 the United Nations Human Rights Subcommission of the WHO assured governments of its readiness, together with Unicef, to support national efforts against FGM.
The WHO then condemned the practice in 1986, as did the International Planned Parenthood Foundation, and the African Charter on the Rights and Welfare of the Child was passed. The Foundation for Women's Health, Research and Development (FORWARD) has campaigned in Britain and elsewhere for the abolition of FGM.
The most recent Act of 2003 was set up to re-state the law relating to FGM but in particular reference to preventing children being taken out of the country for the ritual.
Child protection and FGM
In Britain FGM is a form of child abuse. FGM differs from other forms of child abuse, in that it is done by the family with the best intentions and approval of the community for the future welfare of the child.
Unfortunately, the normal presentation occurs after a girl has had the procedure; there is therefore no point in prosecuting the parents for something which has already occurred. Younger girls in the family would still be at risk; they will need monitoring.
However a teacher or healthcare worker may suspect that a family is preparing to have their child sent away to have the operation. The child may refer to a trip overseas, a special procedure, a pinching of their bottom.
Anyone, not necessarily a health professional or social worker, can report his or her suspicions to the social services department. A child thought to be at immediate risk can be placed under an emergency protection order (EPO).
Knowledge of FGM among healthcare workers in the UK
A recent study in the Midlands 6 has recently identified that only 40% of medical staff in a university teaching hospital were familiar with the regulations of the FGM Act of 2003. More worryingly, approximately 50% incorrectly thought that Caesarean section is the best way of managing FGM if vaginal examination is not possible in the first stage of labour. This study highlights the need for improvements in medical education and practice.
Effective medical care for FGM victims
The first clinic devoted specifically to the needs of circumcised women was started at Northwick Park Hospital in Harrow in 1993, and the experience there has been documented. 7–9
In 1997 a new clinic was set up at the Central Middlesex Hospital in West London and this clinic was funded by a grant from the Department of Health. This clinic offered both expert medical advice in antenatal care and also gynaecology (it was staffed by two consultant obstetricians and gynaecologists), and offered family planning advice and psychological support. The aim of the clinic was to support the cohort of women who had been circumcised in not allowing their young daughters to become victims of FGM. The most impressive development was that within six months of opening, we were seeing victims of FGM seeking reversal of circumcision before marriage and before pregnancy. There was a routine service for reversal of circumcision, which was carried out between 18–20 weeks of pregnancy under a spinal anaesthetic. This was set up to avoid any ‘emergency procedures’ during labour. The consultants also carried out pre-conception reversals on our routine gynaecological lists.
The latest Confidential Enquiry into Maternal and Child Health has confirmed our belief that antenatal reversal of FGM reduces the Caesarean section rate and maternal mortality.
Reversal of FGM: the method
In most cases, the surgical procedure is straightforward. The scar is opened strictly in the midline until the urethra is exposed. This part of the operation is relatively bloodless. The incision can then be extended forward carefully to expose the clitoral area. The site of the clitoris may very from 1–5 cm anterior to the urethra. In the majority of cases, the clitoris will be found intact and undamaged. At the end of the procedure, the raw areas should be over-sewn using a fine (3–4/0) absorbable continuous suture. This prevents any oozing from the suture line and reduces the chance of subsequent labial adhesion formation.
One major problem involves women who either decline antenatal reversal or simply slip through the net and present in labour with an intact circumcision. This is a situation which is much feared by inexperienced midwives and junior doctors. The woman is often in advanced labour and there is danger of extensive perineal trauma. The solution is in fact perfectly simple. The scar should be incised again, keeping strictly to the midline, until the urethra is exposed. This allows maximum room for delivery and makes it possible to catheterize the bladder when needed to prevent obstruction to the baby's head. Blood loss is usually negligible and any suturing can be left until after delivery. After reversal, episiotomy may or may not be required and should be decided on an individual basis (Table 2).
Timing of reversal operations: Central Middlesex study
Complications of FGM reversal
The most common added problem was the presence of epidermal cysts which occurred in 12 cases. These are usually small (less than 1 cm) but in two cases they were large, obstructing the introitus.
One woman in the Central Middlesex Study had a urethral fibroma. There were three cases of reformed labial adhesions causing a barrier at the introitus and requiring division under local anaesthetic. The primary surgery in all three cases was carried out in other countries. Two women presented with pain and vaginismus related to small neuromas in the clitoral area and one woman with similar pathology presented with intensely painful orgasms. All these three women had a primary reversal with no attempt at exposing the clitoris, the reversals being carried out in Somalia. All three were cured after appropriate surgery (Table 3).
State of clitoris: African Clinic, Central Middlesex Hospital
Those ‘not recorded’ were in labour and no attempt was made to dissect the clitoral area.
FGM is associated with an increased perinatal mortality
It is now well established that in Africa, genital mutilation is associated with an increased perinatal mortality. 10 It is by no means certain if this occurs in European practice and the few published studies give conflicting results. 11 Although there is some evidence of increased mortality in immigrants from sub-Saharan Africa, 11 there is no good evidence linking this with genital mutilation. 12
Conclusion
There are now several Wellwoman African Clinics offering support for women who have been victims of FGM. These clinics are successful because of the use of link workers who support the pregnant women and patients who attend them. They also provide an environment to teach healthcare professionals and to reduce risk through ignorance.
Obstetricians and midwives have a duty to be aware of the ‘high-risk’ nature of their clients and to offer them appropriate advice and treatment. These clinics have been shown to be both culturally acceptable and effective within the Somali community. This supportive approach, along with the finding that younger Somali women are seeking premarital and preconception reversal, indicates that the practice will die out within a few generations. Until that happens, the risk of FGM should be recognized as legitimate grounds for refugee and asylum status.
Dedication
This paper is dedicated to the memory of my father, Norman Morris, an obstetrician who revolutionized obstetric practices in the 1960s. He died in February 2008.