Female genital mutilation, the taboo subject [Archives:2006/954/Health]

June 12 2006

Amel Al-Ariqi
[email protected]

Female genital mutilation (FGM) is a very serious subject but also a very sensitive issue in Yemen. Many people dare not speak about it, while some would rather forget it, claiming that it's not a real problem in Yemen. However, such denial doesn't prevent the fact that many international organizations classify Yemen as one of at least 28 nations worldwide that practice FGM.

According to the U.S. Agency for International Development (USAID), which funded the 1997 Yemen Demographic Mother and Child Health Survey, 23 percent of Yemeni women have undergone FGM procedures. In sparsely-populated Red Sea and Aden coastal regions, the figure rises to 69 percent, compared with 15 percent in the heavily-populated highlands and five percent in plateau and desert regions.

The Pacific Institute for Women's Health (PIWH) conducted a 2000 study on FGM, focusing on five Yemeni governorates – Sana'a city, Hodeidah, Hadramout, Aden and Al-Mahara. The study, which included 2,163 women, sought to determine the extent of the practice and analyze its attitudinal and physiological aspects.

The PIWH study indicated that more than 97 percent of respondents in Hodeidah had experienced FGM, 96 percent in Al-Mahara and Hadramout, 82 percent in Aden and 45.5 percent in Sana'a.

Some professionals who read the study were shocked and disputed the figures, saying that the areas where interviews were conducted had a high percentage of immigrant populations, leading to inflated numbers of women who had FGM performed on them.

However, Soheir Stolba, Ph.D., who worked in Yemen in this field, confirmed, “Most educated Yemenis denied the custom's existence, attributing it only to limited coastal pockets of populations where African immigrants live. My continued work on this phenomenon over a six-year period revealed that FGM is deeply rooted in Yemen.”

Female circumcision and Takmeed

Often referred to as 'female circumcision,' FGM includes all procedures involving partial or total removal of external female genitalia or other injury to female genital organs.

Stolba referred to another practice performed on female genitalia in Yemeni coastal areas, known locally as Al-Takmeed. On the fourth day after a baby girl's birth, her mother or an older female household member prepares a compress to use on the genitalia. The compress is a soft cotton material inside of which heated salt and/or sand is placed, along with oil and herbs.

The mother heats the compress and places it on the infant's genitalia, pressing repeatedly for about an hour. This continues for a period varying between 40 days and four months. The procedure's physical effect may affect nerve endings and decrease sexual excitement of the girl or woman on whom it is performed.

According to UNICEF, FGM still is practiced on approximately two million girls annually. Amnesty International estimates that some 135 million girls worldwide have undergone some form of FGM.

Health consequences of FGM

FGM's immediate and long-term health consequences vary according to the type and severity of the procedure performed. Immediate complications include severe pain, shock, hemorrhaging, urine retention, ulcerating the genital region and injuring adjacent tissue. Bleeding and infection can cause death.

According to Stolba, infection results from using unsterile cutting instruments like razor blades or scissors and improperly treated tetanus infection can be lethal. Unsterile instruments also may contribute to the spread of HIV, as in some African nations. Additionally, urine and feces easily can infect the wounds.

Most cutting is done without anesthesia in an unsterile environment, such as a girls' home (a secluded hut) or a traditional barber shop. Even when local anesthesia is used, pain in the highly sensitive clitoral area returns within two or three hours of the operation.

Swelling resulting from trauma in front of the vulva may cause a girl to withhold urinating for hours, fearing a burning sensation and/or pain. According to Stolba, this also may lead to or exacerbate kidney and bladder infections.

Regarding psychosexual and psychological health, FGM may leave a lasting mark on the life and mind of the woman who has experienced it. In the longer term, women may suffer feelings of incompleteness, anxiety and depression.

The most common complications are scarring and reproductive tract infections (RTIs), which often are ignored and unreported by women for fear of being accused of infidelity or lack of cleanliness. Stolba noted that women tolerate the pain and often experience complications resulting from repeated RTIs.

A newly-published (June 2) World Health Organization (WHO) study showed that women who've had FGM are significantly more likely to experience difficulties during childbirth and their babies are more likely to die as a result of the practice.

Serious complications during childbirth include the need to have a Caesarean section, dangerously heavy bleeding after the baby's birth and prolonged hospitalization following the birth. The study found that the degree of complications increased according to the extent and severity of FGM.

“As a result of this study, for the first time, we have evidence that deliveries among women subjected to FGM are significantly more likely to be complicated and dangerous,” said Joy Phumaphi, Assistant Director-General of Family and Community Health at WHO.

The study also found that FGM put women's babies in substantial danger during childbirth, as researchers found that there was an increased need to resuscitate infants whose mothers had FGM.

“This research was conducted in hospitals where the obstetric staff is used to dealing with women who have had FGM. The consequences for the countless women and babies who deliver at home – without the help of experienced staff – are likely to be even worse,” added WHO's Dr. Paul Van Look, Director of the Special Program for Human Reproduction Research, which organized the study.

Who and where?

Returning to the PIWH study, many Yemeni parents take their daughters to trained medical personnel, as educated parents able to pay the high price of physicians prefer using them. “Many parents prefer using physicians or nurses because they want the procedure performed under hygienic conditions,” the study mentioned.

However, another study revealed that trained medical personnel perform only 10 percent of such operations. Women specialized in ear piercing, birthing attendants, rayissas (women skilled in female circumcision) and relatives conduct most FGM procedures.

According to the study, the procedure is conducted 95 percent of the time at home and mothers are the primary decision-makers in determining if their daughters will undergo it.

USAID's Demographic and Health Survey found that nearly all reported procedures (97 percent) occurred during the first month of life. Health facilities housed only three percent of these, while 97 percent were performed at home, with a traditional birthing attendant (68 percent) or elderly female relative (19 percent) usually performing the procedure. Nurses, midwives and doctors perform seven percent of FGM procedures, whereas barbers perform five percent. The usual tool is a razor blade, although scissors are used 20 percent of the time.

Why FGM still is practiced

Studies reveal that FGM is not indigenous to Yemen. In the past, Yemeni populations didn't practice FGM, so its history in Yemen seems to be recent, but there is no definitive data on such history. However, many Yemenis believe recent migrations from Africa, particularly from Somalia and other East African nations, to Yemeni coastal towns have led to the custom's spread in large cities like Aden and Hodeidah. The practice found fertile ground in Yemeni conservatism, with Yemeni society creating a new form of FGM called Takmeed.

“The reasons for female genital cutting vary from one place to another, even within the same country,” Stolba said. The most common reasons given in Yemen are cleanliness and religious/cultural tradition, as well as a common belief that the practice serves to temper female sexual urges.

“Those who support the practice claim it's an important part of the ritual of becoming a woman. Some groups suggest it has religious significance, especially common among some conservative Muslims. However, it's important to note that there is no doctrinal basis for female genital cutting in either Islam or Christianity. Furthermore, there are no Qur'anic citations that support this practice,” she explained.

Challenges and efforts

FGM is not a priority issue for any Yemeni group, as men don't talk about the custom and women seem content with the situation because they think it's sanctioned by religion. Not many choose to talk about FGM politically or developmentally due to fear from conservative segments of the population. Moreover, there's no law against FGM in Yemen; however, a January 9, 2001 ministerial decree prohibits the practice in both government and private health facilities.

Despite public sensitivity about the issue, campaigns to eliminate FGM are being conducted in some regions. In a departure from the past, some of the largest public and private NGOs devoted to women's issues are running public awareness campaigns.

“Conservative groups have rejected international assistance to fight female genital cutting. Some consider foreign funding for public education initiatives a form of meddling or a conspiracy to cast a negative image on non-Western cultures. Others defend the practice and condemn international and local organizations that advocate eliminating it,” Stolba noted.

“It's crucial for local groups where FGM is practiced to be involved and advocate its elimination. Outsiders' interference can only make matters worse if they're not working closely with local groups. However, outsiders may work collaboratively with local women's organizations to facilitate access to funding or provide technical assistance, if needed,” she added.

“It's important to realize that the battle to eliminate female genital cutting is a process that starts with educating parents and community leaders about its negative health impact on girls' and women's health,” Stolba emphasized.

According to her, this process can be conducted by increased funding to government health care agencies to educate and train health care practitioners, increased public education efforts by NGOs and other entities and sensitive yet informative media campaigns. “In time, this practice can be eliminated gradually” she added.

An important aspect of such effort will be to take this campaign to conservative rural areas via government health care practitioners at rural clinics, training and re-educating traditional midwives and community education efforts by NGOs working in rural areas.