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Female genital mutilation: more common than you think

Comfort Momoh
RN RM FPCert
BSc in Women's Health
FGM/Public Health Specialist
African Well Woman's Clinic Guy's and St Thomas' Foundation Trust
London

Vice-President
European Network on FGM (EURONET)

Chair
Black Woman's Health and Family Support

Currently studying for MSc in Health Promotion/Health Education
E:comfort.momoh@gstt.sthames.nhs.uk

Female genital mutilation (FGM) is an ancient traditional practice common in Africa and the Middle East, whereby a woman's external genitals are totally or partially removed. It is not associated with any one religious group, but is practised by Muslims, Christians and Jews alike. The origin of this practice is not well known - some say that it started in Egypt during Pharaonic times, while others believe that it started well before then.
What is definitely known is that FGM is a violation of human, women and children's rights. FGM has no health or medical benefit.
However, the practising communities see it as an act of love and a rite of passage to womanhood. In many countries FGM is an accepted and expected custom, and for many women it is a fact of life, a pain that must be borne because they must conform to social expectation in order to survive. Some believe that undergoing the circumcision will give them a sense of belonging to and acceptance by society or a particular group.

Who performs female genital mutilation?
FGM is usually performed by an elderly family ­member or lay person with little or no training.
It is usually performed on girls between the ages of 4 and 13, but there have been cases of newborn babies undergoing FGM or young women before marriage or pregnancy. It is often performed in unhygienic locations and without anaesthesia.
An estimated 130 million women worldwide have undergone FGM, mainly in Africa, the Middle East and Indonesia.(1,2) However, immigration and the rise in asylum seekers and refugees have meant that there are many women who have undergone FGM now residing in the UK, and health and social professionals need to be aware of this practice. Primary care nurses in particular have a big role in caring for women and girls with FGM as they are usually the first contact.

Types of female genital mutilation
The World Health Organization (WHO) defines FGM as all procedures involving partial or total removal of the external female genitalia, or any injury to the female genital organs whether for cultural or other nontherapeutic reasons.(1)
The WHO classifies FGM into four types:

  • Type 1: excision of the prepuce, with or without excision of part or all of the clitoris.
  • Type 2: excision of the clitoris with partial or total excision of the labia minora.
  • Type 3: excision of part or all the external genitalia and stitching/narrowing of the vaginal opening, also known as infibulation.
  • Type 4: unclassified; this includes pricking, ­piercing or incising of the clitoris and/or labia, stretching of the clitoris and/or labia, cauterisation by burning of the clitoris and surrounding tissue.

Table 1 lists some of the countries where FGM is known to be practised.

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Reasons given for the practice and why the practice continues
There are many reasons and myths given for the ­existence and continuation of FGM, including:

  • Tradition or culture.
  • Religion - some Muslims believe that FGM is a religious obligation. However, FGM is not ­mentioned in the Koran, it predates Islam, and it is not practised in many Muslim countries.
  • Preservation of virginity. Some communities believe that FGM ensures virginity, as sex before marriage is taboo.
  • To promote cleanliness and beautification.
  • Fear of social criticism, along with a sense of belonging to the community.
  • Prevention of rape.
  • Socioeconomic - FGM is a source of income for circumcisers.
  • Aesthetic reasons.

Facts about female genital mutilation
Ten per cent of girls and women die from the short-term complications of FGM, such as haemorrhage, shock and infection. Another 25% die in the long term as a result of ­recurrent urinary and vaginal infections and complications during childbirth, such as severe bleeding and obstructed labour.
 
Complications and consequences of FGM
FGM is associated with a high incidence of complications that involve short- and long-term adverse effects on the physical, psychological and social wellbeing of the women or young girls involved. In some cases the operation may be fatal.

Immediate complications
Shock: FGM is usually performed without anaesthetic, and the resulting pain and fear usually lead to shock.
Bleeding: Excessive loss of blood can occur with all types of FGM and is sometimes life-threatening.
Accidental damage to surrounding organs: This can occur at the time of circumcision due to the child or women struggling.
Urinary complications: Urinary complications can arise from fear of passing urine in the raw area, or from tight sewing. Acute urinary retention is a well-known complication that occurs within 48 hours of the operation.

Long-term complications
Haematocolpos: This is the closure of the vaginal opening by scar tissue with the serious result that menstrual blood can accumulate inside the woman over many months.
Keloid scars: These are caused by the slow and incomplete healing of the wound and infection after the operation.
Cysts and abscesses on the vulva
Rectal and/or vaginal fistula: This occurs when a rupture is made in the rectal wall or the bladder and results in loss of control and faecal or urinal leakage. It can be a distressing condition.
Rupture of the urethra or permanent damage to other organs
Permanent difficulty in urinating: This may be caused by damage to the urethral opening or by acute infection of the urethra and bladder (which can occur if the person is unable to empty her bladder completely).
Infection: In most cases the operation is performed under very unhygienic conditions by an untrained person. Equipment is very rarely sterilised, and fatal cases of tetanus have been known, as well as hepatitis and HIV infection.
Effect on sexual intercourse: If infibulation (suturing together of the labia to prevent sexual intercourse) has taken place, the woman can find sexual intercourse difficult or impossible, and this can lead to emotional and psychological problems, as well as marital problems between husband and wife.
Effect on general healthcare: The pain of vaginal penetration can make gynaecological examination difficult, and the general healthcare of the woman is likely to suffer.
Pelvic inflammatory disease and infertility: FGM may result in painful inflammation of the pelvic area, and possible infertility.
Problems in labour and in childbirth: If the woman is pregnant, labour may be difficult or even life-threatening for both mother and baby. If the tissues of the vulva have been sewn together in infibulation, they will have to be opened to enable the woman to have a vaginal delivery, and the woman's labour may be prolonged due to the tough and unyielding scar tissue. Delays in the second stage of labour may result in the baby being stillborn, or may cause the uterus or rectum to rupture with internal bleeding, in some cases leading to death.

Current situation in the UK
FGM is illegal in the UK - the prohibition of Female Circumcision Act passed in Britain in July 1985 outlaws the practice. However, despite the law, the practice still continues secretly in this country. Children are sometimes taken back to Africa or other parts of the world during summer holidays to be circumcised.
In 2003, the UK law was amended to ensure that UK residents and nationals who take girls abroad to have them circumcised would be prosecuted on their return, regardless of the status of FGM in the country where the circumcision takes place.

The African Well Woman's Clinic
In 1996, a multidisciplinary working group within Lambeth, Southwark and Lewisham concluded that there was a significant increase in the number of women and girls with FGM attending maternity, gynaecology and family planning clinics. This led to the setting up of the African Well Woman's Clinic at Guy's and St Thomas' Foundation Trust in London in September 1997, to provide a support service for women and girls in the community who have undergone circumcision.
The author runs the clinic along with a female consultant obstetrician.

Referrals to the clinic
Referral to the clinic can be made by all professionals. Nongovernmental organisations (NGOs) or any other organisation can also refer women to the clinic. Women can self-refer themselves.
The clinic is very flexible: we arrange appointments that are suitable to each woman, and we try to meet individual needs. A one-stop clinic is also available where women with FGM can be counselled, advised and have their circumcision reversed, all on the same day.
The clinic offers:

  • Advice.
  • Information.
  • Counselling.
  • Surgical deinfibulation (same-day reversal available with a local anaesthetic for both pregnant and ­nonpregnant women).
  • More links with the community.
  • More autonomy and empowerment.
  • Easy access for women and the community.

The clinic also offers training to GPs, midwives, nurses, and other health-/social care and nonhealthcare professionals, comprising the following:

  • Overview of FGM.
  • Cultural/historical background of FGM.
  • Facts and figures, the law and FGM.
  • Complications of FGM.
  • Pregnancy/labour.
  • Principles to be followed when FGM is suspected or has been performed.

The role of the nurse is to identify women and girls with FGM; provide appropriate care and support; assess the individual's needs in a holistic and ­sensitive way (using an interpreter is essential); and refer women and girls with FGM to the appropriate clinic and NGOs for support.
All health and social professionals have a duty of care and responsibility to protect children who are at risk of FGM.

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References

  1. World Health Organization. FGM:a joint statement. Geneva: WHO; 1997.
  2. Toubia N. A technical manual for health care providers caring for women with circumcision. New York: Rainbo; 1999.
  3. Momoh C. FGM, also known as female circumcision - information for health professionals. London: Guy's & St Thomas Foundation Hospital; 2003.

Resources
The African Well Woman's Clinic
St Thomas Hospital
7th Floor
North Wing
c/o Antenatal Ward
London SE1 7EH
T:020 7188 6872/
T:07956 542576
E:comfort.momoh@gstt.sthames.nhs.uk
Pager:0870 0555500(code 881018)

Global Consultant on  Public Health
10a Russell Garden
Whetstone
London N20 0TR
T:020 8361 9372
T:07956 407063
W:www.fgmconsultancy.com

Black Women's Health and Family Support
82 Russia Lane
Bethnal Green
London E2 9LU
T:020 8980 3503
Foundation for Women's Health
Research & Development (FORWARD)765-767 Harrow Road
London
NW10 5NY
T:020 8960 4000
F:020 8960 4014

Agency for Culture
11A Arundel Gate
Sheffield S1 2PN
T:0114 275 0193

African Women's Clinic
The Elizabeth Garret Anderson and Obstetric Hospital
London
T:020 7383 4937

African Well Woman's Clinic
Antenatal Clinic
Central Middlesex Hospital
London
T:020 8965 5733

Rainbo Research, Action and Information Network for the Bodily Integrity of Women
T:020 7625 3400

Midlands Refugee Council
5th Floor
Smithfield House
Digbeth B5 6BS
Contact: Eklas Ahmed
T:0121 242 2200

EURONET European Network against FGM
W:european_fgm_network@yahoogroups.com

Further ­reading
FGM: female ­circumcision
Gordon H. Diplomate 1998;5:86-90.
Attitudes to female genital mutilation Momoh C. Br J Midwifery 2004; 12(10):631-5.