Female genital mutilation

 

Female genital mutilation (FGM) is a global problem which affects girls and women worldwide.  Although it is internationally recognized as a violation of human rights and legislation to prohibit the procedure has been put in place in many countries, the practice is still being reported.

Female genital mutilation (FGM) includes procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons. FGM comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons1.

Every year about 3 million girls and women are at risk of FGM2. FGM can have a negative effect on several aspects of a girl’s or woman’s life, including her physical, mental and sexual health and her relationship with her husband or partner and other close family members.

FGM is mostly carried out on young girls between infancy and age 15. More than 200 million girls and women alive today have been subjected to the practice in 30 countries in Africa, the Middle East and Asia where FGM is more common3

FGM is recognized internationally as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person's rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death.

Human Rights violated by the practice of FGM4:

  • Right to the highest attainable standard of health
  • Right to life and physical integrity, including freedom from violence
  • Right to freedom from torture or cruel, inhuman or degrading treatment
  • Right to equality and non-discrimination on the basis of sex
  • Rights of the child

The practice is mostly carried out by traditional circumcisers, who often play other central roles in communities, such as attending childbirths. In many settings, health care providers perform FGM due to the erroneous belief that the procedure is safer when medicalized. WHO strongly urges health professionals not to perform such procedures.

In 2008, the World Health Assembly passed resolution (WHA61.16) on the elimination of FGM, emphasizing the need for concerted action in all sectors - health, education, finance, justice and women's affairs. In 2012, the United Nations General Assembly adopted a resolution on the elimination of female genital mutilation3.

In 2015, the Sustainable Development Goals (SDGs) includes a target under Goal 5 to eliminate all harmful practices, such as child, early and forced marriage and FGM/C, by the year 2030.

References-

1.apps.who.int/iris/bitstream/handle/10665/272429/9789241513913-eng.pdf?ua=1

2.www.who.int/news-room/fact-sheets/detail/female-genital-mutilation

3.www.unicef.org/media/files/FGMC_2016_brochure_final_UNICEF_SPREAD.pdf

4.apps.who.int/iris/bitstream/handle/10665/206437/9789241549646_eng.pdf;jsessionid=C292C2BFCE6616EA6E61616EB86DD7F8?sequence=1

 

 

Procedures can cause severe bleeding and problems urinating, and later cysts, infections, as well as complications in childbirth and increased risk of newborn deaths.

Immediate complications can include:

  • severe pain
  • excessive bleeding (severe haemorrhage can lead to anaemia))
  • genital tissue swelling
  • fever
  • urinary problems
  • infections e.g., tetanus
  • wound healing problems
  • injury to surrounding genital tissue
  • shock
  • haemorrhage and infection can be severe enough to cause death.

Long-term effects of FGM can include:

  • urinary problems (painful urination, urinary tract infections);
  • vaginal problems (discharge, itching, bacterial vaginosis and other infections);
  • menstrual problems (painful menstruations, difficulty in passing menstrual blood, etc.);
  • scar tissue and keloid;
  • sexual problems (pain during intercourse, decreased satisfaction, etc.);
  • increased risk of childbirth complications (difficult delivery, excessive bleeding, caesarean section, need to resuscitate the baby, etc.) and newborn deaths;
  • need for later surgeries: for example, the FGM procedure that seals or narrows a vaginal opening (type 3) needs to be cut open later to allow for sexual intercourse and childbirth (deinfibulation).
  • psychological problems (depression, anxiety, post-traumatic stress disorder, low self-esteem, etc.). The psychological stress of the procedure may trigger behavioural disturbances in children, closely linked to loss of trust and confidence in caregivers. In the longer term, women may suffer feelings of anxiety and depression.

FGM has no health benefits, and it harms girls and women in many ways. It involves removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls' and women's bodies1,2.

               FGM: No health benefits, only harm

References-

1.www.who.int/news-room/fact-sheets/detail/female-genital-mutilation

2.apps.who.int/iris/bitstream/handle/10665/206437/9789241549646_eng.pdf;jsessionid=C292C2BFCE6616EA6E61616EB86DD7F8?sequence=1

 

Who is at risk?

Procedures for FGM are mostly carried out on young girls sometime between infancy and adolescence, and occasionally on adult women. More than 3 million girls are estimated to be at risk for FGM annually1.

The practice is most common in the western, eastern, and north-eastern regions of Africa, in some countries the Middle East and Asia, as well as among migrants from these areas. FGM is therefore a global concern2.

Cultural and social factors for performing FGM:

FGM is carried out for various cultural, religious and social reasons within families and communities in the mistaken belief that it will benefit the girl in some way such as- a rite of passage into womanhood, to preserve a girl’s virginity until marriage. Following are some reasons:

Respect for tradition: Community members, including the women see it as a sign of respect towards the elder members of the community.

Rite of passage: In many cultures, FGM constitutes an important rite of passage into adulthood for girls. It may be considered a necessary step towards being viewed as a respectable adult woman.

Social convention: Those who adhere to the practice may be better accepted in their communities, while those who do not may face condemnation, harassment and exclusion.

Enhance fertility: In some practicing communities, women and men believe that if a woman is not cut she will not be able to become pregnant or she may face difficulties during labour.

Marriageability: There is often an expectation that men will marry only women who have undergone FGM. The desire and pressure to be married, and the economic and social security that may come with marriage, can perpetuate the practice in some settings.

Ensure virginity, chastity and faithfulness:  FGM is believed to safeguard a girl’s or woman’s virginity prior to marriage and ensure fidelity after marriage.

Cleanliness and beauty: In some communities, FGM is performed in order to make girls “clean” and beautiful. Cleanliness may refer to the body, but it may also refer to spiritual purity.

Femininity: The removal of genital parts that are considered masculine (i.e. the clitoris) is considered to make girls more feminine, respectable and beautiful.

Religion: Some communities believe that FGM is a religious requirement, and some religious leaders may promote the practice, even though it is not mentioned in any major religious texts3,4.

Medicalization of FGM:

Medicalization of FGM refers to situations in which FGM is practised by any category of health-care provider, whether in a public or a private clinic, at home or elsewhere. It also includes the procedure of re-infibulation at any time in a woman’s life.

(Re-infibulation: The procedure to narrow the vaginal opening in a woman after she has been deinfibulated (such as after childbirth); also known as re-suturing2.

Types of FGM

Female genital mutilation is classified into 4 major types:

  • Type 1: Often referred to as clitoridectomy, this is the partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals), and in very rare cases, only the prepuce (the fold of skin surrounding the clitoris).
  • Type 2: Often referred to as excision, this is the partial or total removal of the clitoris and the labia minora (the inner folds of the vulva), with or without excision of the labia majora (the outer folds of skin of the vulva).
  • Type 3 (infibulation): Often referred to 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 labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoris (clitoridectomy).
  • Type 4: This includes all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area2.

References-

1www.unicef.org/media/files/FGMC_2016_brochure_final_UNICEF_SPREAD.pdf

2.www.who.int/news-room/fact-sheets/detail/female-genital-mutilation

apps.who.int/iris/bitstream/handle/10665/272429/9789241513913-eng.pdf?ua=1

 

Health-care providers working in regions where FGM is a common practice and those seeing patients from these regions should always include direct questions about FGM-related gynaecological and urogenital complications when taking a medical history from their female patients1.  As girls and women living with FGM often do not seek care for such type of symptoms until the symptoms are advanced or cannot be hidden.

Once it has been established that the girl or woman has undergone any type of FGM, this information and the subsequent clinical examination should be done with proper care. Following tests may be performed according to the symptoms:

  • Rapid diagnostic tests (RDTs) for diagnosis of sexually transmitted infections
  • Urine examination when symptoms suggestive for urinary tract infections 
  • Pelvic ultrasound to confirm the cause in case of menstrual irregularities.

Reference-

1.apps.who.int/iris/bitstream/handle/10665/272429/9789241513913-eng.pdf?ua=1

 

 

Health-care providers play an important role in the treatment and care of the girls and women around the world living with female genital mutilation1,3.

Girls and women gone through FGM, may have symptoms related to gynecological problems menstrual problems, pelvic pain, painful intercourse, difficult labour, depression, anxiety and other problems and they should consult health care provider in their areas.

Many women who have undergone FGM have greater risk of obstetric complications, hence adequate and timely antenatal care and birth plan in advance for child birth should be taken to ensure the healthiest possible outcome for the woman and the baby.

Sometimes surgery called deinfibulation may be required in women living with Type III FGM to re-open the vaginal introitus. It is recommended for preventing and treating obstetric complications in women living with type III FGM1.

In the case of asymptomatic women living with FGM who request surgery, interventions are performed on the basis of clinical judgement, the management of these cases should always start with the least invasive procedure available as several potential adverse events are associated with surgical interventions.

Cognitive behavior therapy(CBT): A type of psychological therapy based on the idea that feelings are affected by thinking and beliefs. If unchecked, these thoughts and beliefs can lead to unhelpful behaviours. CBT typically has a cognitive component (i.e. helping the person develop the ability to identify and challenge unrealistic negative thoughts) and a behavioural component.

CBT may be considered in women, girls who are diagnosed with psychiatric problems such as anxiety disorder, depression or post-traumatic stress disorder (PTSD). The therapy should be provided by competent individuals (trained and supervised)1,2.  

References-

1. apps.who.int/iris/bitstream/handle/10665/272429/9789241513913-eng.pdf?ua=1

2.apps.who.int/iris/bitstream/handle/10665/206437/9789241549646_eng.pdf;jsessionid=C292C2BFCE6616EA6E61616EB86DD7F8?sequence=1

3. www.who.int/reproductivehealth/publications/fgm/fgm-slides-final.pdf?ua=1

 

 

Women who are living with FGM often are at increased risk of developing complications during pregnancy and childbirth. They should consult their health care provider during this period.

Reference.

apps.who.int/iris/bitstream/handle/10665/272429/9789241513913-eng.pdf?ua=1

FGM has no health benefits, and it harms girls and women in many ways. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. Despite this, a number of myths and misconceptions about FGM persist, which support the perpetuation of this harmful practice1.

One such myth that families and individuals often wrongly believe, is that FGM would be safer if carried out by a health care provider. Some health care providers are also under the misconception that by carrying out FGM they are preventing harm to girls or women. There is no medical justification for FGM, and medical practitioners carrying out FGM on girls and women are causing only harm.

In the recent years, there has been a dramatic increase in the proportion of FGM operations carried out by trained health-care personnel. However, World Health Organisation is strongly opposed to health care providers carrying out FGM1,2.

There is a challenge not only protecting girls who are currently at risk but also ensuring that those to be born in the future will be free from the dangers of the practice. This is especially important considering that FGM-concentrated countries are generally experiencing high population growth and have large youth populations. In 2015, an estimated 3.9 million girls were subjected to FGM. This number of girls cut each year is projected to rise to 4.6 million girls in the year 20303.

International response1

In 1997, WHO issued a joint statement against the practice of FGM together with the United Nations Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA). Since 1997, great efforts have been made to counteract FGM, through research, work within communities, and changes in public policy.

In 2007, UNFPA and UNICEF initiated the Joint Programme on Female Genital Mutilation/Cutting to accelerate the abandonment of the practice.

In 2008, the World Health Assembly passed resolution WHA61.16 on the elimination of FGM, emphasizing the need for concerted action in all sectors - health, education, finance, justice and women's affairs.

In 2008, WHO together with 9 other United Nations partners, issued a statement on the elimination of FGM to support increased advocacy for its abandonment, called: “Eliminating female genital mutilation: an interagency statement”. This statement provided evidence collected over the previous decade about the practice of FGM.

In 2010, WHO published a "Global strategy to stop health care providers from performing female genital mutilation" in collaboration with other key UN agencies and international organizations.

In December 2012, the UN General Assembly adopted a resolution on the elimination of female genital mutilation.

The Sustainable Development Goals in 2015 calls for an end to FGM by 2030 under goal 5 on gender equality, target 5.3 eliminate all harmful practices, such as child, early and forced marriage and female genital mutilation.

In May 2016, WHO in collaboration with the UNFPA-UNICEF joint programme on FGM launched the first evidence-based guidelines on the management of health complications from FGM.

To promote the elimination of FGM, coordinated and systematic efforts are needed, and they must engage whole communities and focus on human rights and gender equality.

International Day of Zero Tolerance to Female Genital Mutilation is observed on February 6 to raise awareness and educate people about the dangers of female genital mutilation (FGM) and to take concrete actions against it.

References-

1.www.who.int/news-room/fact-sheets/detail/female-genital-mutilation

2.www.unfpa.org/resources/female-genital-mutilation-fgm-frequently-asked-questions

3.www.unfpa.org/press/nearly-70-million-girls-face-genital-mutilation-2030-unfpa-warns

4.apps.who.int/iris/bitstream/handle/10665/272429/9789241513913-eng.pdf?ua=1

 

 

MYTH

There are many myths about FGM1….

  • FGM is a religious obligation. False

FGM is not supported in any religious texts and moreover many religious leaders believe that this tradition should end.

  • Only girls who undergo FGM can enter womanhood and be considered respectable. False  

Cultural norms are changing and alternative rites of passage into womanhood that do not involve FGM are increasingly accepted.

  • Men do not support abandonment of FGM. False

In most countries, the majority of boys and men think FGM should end.

  • If FGM is performed by a health-care professional, there is no risk of harm. False

FGM is a harmful practice and may lead to physical, mental and sexual health complications regardless of who performs it.

  • FGM can improve fertility. False

There is no evidence that FGM improves fertility but complications of FGM can negatively impact fertility.

Important

Health-care providers should not perform FGM. If they perform FGM, they are only violating the fundamental medical ethic to “Do no harm” and the fundamental principle of providing the highest quality health care possible2.

Myth about FGM    

References

1www.who.int/reproductivehealth/publications/fgm/FGM_infographics/en/

2.www.who.int/news-room/fact-sheets/detail/female-genital-mutilation

 

 

  • PUBLISHED DATE : Apr 16, 2019
  • PUBLISHED BY : NHP Admin
  • CREATED / VALIDATED BY : Dr. Aruna Rastogi
  • LAST UPDATED ON : Apr 16, 2019

Discussion

Write your comments

This question is for preventing automated spam submissions
The content on this page has been supervised by the Nodal Officer, Project Director and Assistant Director (Medical) of Centre for Health Informatics. Relevant references are cited on each page.