Understanding Female genital mutilation

Female genital mutilation (FGM) has its roots in African tradition. There are different types of FGM ranging from partial to complete removal of the clitoris as well as other procedures including “pricking, piercing, incising, scraping and cauterizing the genital area”. The removal of healthy tissue not only interferes with the natural functions of girls' and women's bodies but often results in immediate acute pain, shock, severe bleeding, and bacterial infection as well long term recurrent urinary tract and bladder infections, complications in childbirth and often leads to painful sexual intercourse. UNICEF estimates that “at least 120 million girls and women have undergone FGM in Africa and the Middle East”.

Thankfully the popularity of FGM is declining however, up to 30 million girls may still be at risk, with “more than 90 per cent of women aged 15–49 years having been ‘cut’ in Djibouti, Egypt, Guinea and Somalia.” Although FGM is illegal in the UK, it is difficult to ensure that families don’t encourage the tradition especially as it is common among migrants from the aforementioned areas to send young girls back to their ancestral homelands to undergo the procedure, usually over the duration of the summer holidays. According to Human rights organization Equality Now it is estimated that “66,000 women and girls have undergone FGM in England and Wales” and up to “24,000 girls under the age of 11 are at risk of undergoing it”. The Evening Standard carried out a Freedom of Information request which found that “over 2,100 women and girls in London have sought medical treatment for female genital mutilation since 2006, with 708 of those needing to be admitted or have surgery.”

Zarah Hassan a devout Muslim living in the UK believes that the barbaric tradition continues to be perpetuated because of the mistaken belief that the practice is rooted in the Koran. She says “sometimes you cannot differentiate what is culture and what is religion: you might think this is the way you have to live.” Zarah actively works with Christian-based charity Initiatives of Change in re-educating her community by encouraging families in the Diaspora not to cave in to immense pressure they face from family members back home who demand they conform and continue the practice.

Pointing out the power exerted by grandparents she says “we have this culture that even if you are a parent, your mother and father are your decision-makers. But if that is the case, don’t take the children out there (to stay with the family over the holidays)”... “I know some grannies who are very powerful, and they will do it (have the girls circumcised) with or without the parents’ consent.” Speaking of some of women she works she says “often, they tell me: ‘My mother is phoning me from back home, telling me it is good to have my daughter circumcised while she is young, under five. She is forcing me.’” As a 51 year old woman who has also been ‘cut’, she believes it is an age old method of controlling women “...it was a form of power-gaining. Men wanted to show the power they have, because when (the vagina) is stitched together, a very narrow gap is left and the man shows his power when he presses there.” She speaks of the ongoing pain suffered during intercourse. Horrifyingly this agony is often re­lived by some women, who are subjected to “re-infibulation”. Re-infibulation is the process of sewing up the vagina again following childbirth, thus exposing the woman to further pain, health risks and undue complications which may result from repeated interfering with the vagina. This is often carried out by the older women, challenging the notion that it is only men who are the perpetrators of this cruel tradition.

It is commonly believed that removing the clitoris controls women’s sexual desire and behavior. It supposedly protects her honour and virginity however; it has no credible health benefit or religious basis. In countries such as Egypt where it is banned and indeed condemned by the Christian Coptic Church together with the leading Muslim authority Al-Azhar, prevalence remains high with a rate of 91% of 15 – 49 year old women having undergone the procedure according to UNICEF, indicating that attitudes are still to change. Indeed until the 1950s, FGM was even performed in England and the United States as a common "treatment" for lesbianism, masturbation, hysteria, epilepsy, and other so-called "female deviances" according to Koso­Thomas. Clearly this method of chastity is effective because a study carried out in Sudan in 1981 found that 50% of 1,545 women who had undergone the operation said “they did not enjoy sex at all and only accepted it as a duty...” a clear indicator that FGM may have a detrimental effect on women’s sexuality.

Hardly surprisingly when FGM oftentimes involves complete removal of the clitoral hood, clitoris, labia minora, and labia majora and/or stitching/narrowing of the vaginal opening. Ill-founded claims that it ensures cleanliness, preserves virginity, prevents promiscuity and excessive clitoral growth need to be challenged. It can hardly enhance male sexuality as it commonly thought when the vaginal opening is often so narrow as to prevent penetration altogether! “5.5 percent of women experienced painful intercourse while 9.3 percent of them reported having difficult or impossible penetration.” And far from facilitating childbirth by widening the birth canal “the highest maternal and infant mortality rates are in FGM­practicing regions” thus detreminentally affecting the lives of even the unborn.

More education is needed to alert men as to the severity and consequences of the practice. Some think it is comparable to male circumcision, not so. FGM is far more drastic as it “destroys much or all of the vulva nerve endings.” Male circumcision involves removal only of foreskin, albeit the part with the highest concentration of nerve endings. Some argue that if female circumcision were done in a sterile hospital room, it would be very much the same as that of a male child however, that argument is a non starter as even male circumcision has already been proven to have long-term physical and psychological effects. So circumcision as a whole leaves a sour taste in everybody’s mouth. However a lot more needs to be done to stop the lives of young girls and women being put at risk.

In 2007 two girls died post operation, followed by 13-year old Nermine El-Haddad who bled to death in a hospital room following the procedure, in 2010. The issue has again risen to the fore following the recent death of Sohair al Bata a 13 year old Egyptian girl who suffered “a sharp drop in blood pressure resulting from shock trauma” and subsequently never woke up. As data is not readily available it is difficult to determine actual death rates and according to Koso-Thomas “where medical facilities are ill-equipped, emergencies arising from the practice cannot be treated... a child who develops uncontrolled bleeding or infection after FGM may die within hours.” According to Path studies carried out “in areas in the Sudan where antibiotics are not available, it is estimated that one-third of the girls undergoing FGM will die.” Furthermore, “conservative estimates suggest that more than one million women in Centrafrican Republic (CAR), Egypt, and Eritrea, the only countries where such data is available, experienced adverse health effects from FGM”. Path also found that “there is a direct correlation between a woman's attitude towards FGM and her place of residence, educational background, and work status” Research indicated that urban and employed women with secondary or higher education are less likely than their rural counterparts to support FGM. Meaning that the way to bring about change is to educate and empower these women.

Wrong ideology needs to addressed and challenged. FGM needs to be taken out of the religious and cultural context and treated as a human rights and child protection issue in order to make perpetrators fully accountable. It is worrying that even though it is illegal in several countries not a single perpetrator has ever been brought to justice. A number of countries ratified or at least adopted The Maputo Protocol (TMP) following the “Assembly of the African Union”.

TMP promoted women’s rights and called for an end to FGM as well as right to abortions. Fast forward to today and the UN has introduced a Global Ban on FGM. Furthermore in the UK Prevention of Cruelty to Children (NSPCC) now considers it to be a child protection issue.

Keir Starmer, the Director of Public Prosecutions (DDP), QC, recently published an Action Plan aimed tackling the problem in the UK.

But it is still very much an exploratory plan rather a provision of concrete solutions because data is very limited. It will throw further light on the issue to enable us to come up with more direct, conclusive solutions, such as demanding greater accountability from parents who send their children abroad for the procedure. Initiatives such as the ‘health passport’ offer a glimmer of hope however they are yet to be tested fully and rely too heavily on cooperation from distant relatives who have been shown to be uncooperative. Thankfully, awareness is increasing.

If you are worried about a child affected or in danger of being affected by FGM please contact NSPCC 0800 028 3550 for information and support.

Alternatively, contact Women's Aid on 0117 944 4411

or helpline@womensaid.org.uk

 

By Katasi Kironde

Female genital mutilation (sometimes referred to as female circumcision) refers to procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons. The practice is illegal in the UK.

It has been estimated that over 20,000 girls under the age of 15 are at risk of female genital mutilation (FGM) in the UK each year, and that 66,000 women in the UK are living with the consequences of FGM. However, the true extent is unknown due to the 'hidden' nature of the crime.

The girls may be taken to their countries of origin so that FGM can be carried out during the summer holidays, allowing them time to 'heal' before they return to school. There are also worries that some girls may have FGM performed in the UK.

Forms of mutilation

FGM is usually carried out on young girls between infancy and age 15, most commonly before puberty starts.

The procedure is traditionally carried out by a woman with no medical training. Anaesthetics and antiseptic treatments are not generally used and the practice is usually carried out using knives, scissors, scalpels, pieces of glass or razor blades. Girls may have to be forcibly restrained.

There are four main types of FGM:

• Type 1 – clitoridectomy – removing part or all of the clitoris.


• Type 2 – excision – removing part or all of the clitoris and the inner labia (lips that surround the vagina), with or without removal of the labia majora (larger outer lips).


• Type 3 – infibulation – narrowing of the vaginal opening by creating a seal, formed by cutting and repositioning the labia.


• Other harmful procedures to the female genitals, which include pricking, piercing, cutting, scraping and burning the area.

Effects of FGM

There are no health benefits to FGM. Removing and damaging healthy and normal female genital tissue interferes with the natural functions of girls' and women's bodies.

Immediate effects

• severe pain


• shock


• bleeding


• wound infections, including tetanus and gangrene, as well as blood-borne viruses such as HIV, hepatitis B and hepatitis C


• inability to urinate


• injury to vulval tissues surrounding the entrance to the vagina


• damage to other organs nearby, such as the urethra (where urine passes) and the bowel

FGM can sometimes cause death.

Long-term consequences

• chronic vaginal and pelvic infections


• abnormal periods


• difficulties passing urine and persistent urine infections


• kidney impairment and possible kidney failure


• damage to the reproductive system, including infertility


• cysts and the formation of scar tissue


• complications in pregnancy and newborn deaths


• pain during sex and lack of pleasurable sensation


• psychological damage, including low libido, depression and anxiety (see below)


• flashbacks during pregnancy and childbirth


• the need for later surgery to open the lower vagina for sexual intercourse and childbirth

Psychological and mental health problems

Case histories and personal accounts taken from women indicate that FGM is an extremely traumatic experience for girls and women, which stays with them for the rest of their lives.

Young women receiving psychological counselling in the UK report feelings of betrayal by parents, regret and anger.

The legal situation

FGM is illegal in the UK. It is also illegal to arrange for a child to be taken abroad for FGM. If caught, offenders face a large fine and a prison sentence of up to 14 years.

What you can do

If you are worried about someone who is at risk of FGM or has had FGM, you must share this information with social care or the police. It is then their responsibility to investigate and protect any girls or women involved.

See the Useful links, right, for contact information.

Health professionals

If you are a health or social care professional who may come into contact with girls and women at risk of FGM, you can read the Multi-Agency Practice Guidelines on Female Genital Mutilation (HMG 2011) (PDF, 1.63Mb).

These guidelines contain detailed advice and guidance in relation to the protection of girls who may be at risk of FGM, as well as the care and treatment of women who have already undergone FGM.

Other useful resources are listed in the Useful links, right.

Surgical "reversal"

Surgery can be performed to open up the lower vagina. This is sometimes called "reversal", although it cannot restore sensitive tissue that has been removed.

Surgery may be necessary for women who are unable to have intercourse as the vagina is too narrow. In addition, some pregnant women who have had FGM will need to have their lower vagina opened up before labour to allow a safer birth.

FGM increases the risk of the vagina tearing during delivery, which causes damage and can lead to heavy bleeding. It can also increase the risk of the baby dying during, or just after birth.

Surgery is best performed before pregnancy, or at least within the second trimester of pregnancy (between about 12 and 36 weeks).

Some women may be reluctant to undergo reversal until labour starts, because this may be normal practice in their country of origin. The Royal College of Nursing 2006 guidelines (PDF, 1.03Mb) offer advice on this.

Surgery involves making a careful incision along the scar tissue that has closed up the entrance to the vagina, to expose the underlying vagina.

Adequate pain relief is essential – the procedure is usually performed under local anaesthetic in the outpatient clinic. However, a small number of women will need either a general or spinal anaesthetic (injection in the back), which would normally involve a one-day stay in hospital.

Where does FGM happen?

FGM is prevalent in Africa, the Middle East and Asia.

In the UK, FGM tends to occur in areas with larger populations of communities who practice FGM, such as first-generation immigrants, refugees and asylum seekers. These areas include London, Cardiff, Manchester, Sheffield, Northampton, Birmingham, Oxford, Crawley, Reading, Slough and Milton Keynes.

Why is it done?

FGM is carried out for cultural, religious and social reasons within families and communities.

For example, it is often considered a necessary part of raising a girl properly, and as a way to prepare her for adulthood and marriage. FGM is often motivated by the belief that it is beneficial for the girl or woman. Many communities believe it will reduce a woman's libido and discourage sexual activity before marriage.

Key points

• Over 66,000 women and girls living in Britain have experienced female genital mutilation (FGM).


• FGM is illegal – it is an offence for anyone to perform FGM in the UK or to arrange for a girl to be taken abroad for it.


• FGM causes long-lasting physical and psychological damage.


• There are 15 specialist clinics in the NHS that offer a range of healthcare services for women and girls who have been subjected to FGM, including reversal surgery. In some areas women can attend without referral, but in other areas a GP referral letter is required.

Statement opposing female genital mutilation

The school summer holidays in particular are when many young girls are taken abroad, often to their family's birth country, to have FGM performed. The FGM statement highlights the fact that FGM is a serious criminal offence in the UK with a maximum penalty of 14 years in prison.

If you're worried about FGM, print out this statement, take it with you abroad and show it to your family. Keep the declaration in your passport, purse or bag and carry it with you all the time.

Download the FGM statement (PDF, 632Kb)

If you work with FGM-practising communities, you may wish to order printed copies for your healthcare setting, youth club or community group. Please e-mail: Alison.Humphreys3@homeoffice.gsi.gov.uk stating the number of copies required and a postal address for them to be sent to.

FGM resources

Find useful links and organisations about female genital mutilation (FGM), including resources for health professionals

FGM inquiry launched to uncover reasons for lack of prosecution in UK

Major inquiry will look at current legal framework's suitability given there has not been a single prosecution in three decades

Alexandra Topping -The Guardian,

Efua Dorkenoo, head of Equality Now's FGM policy: 'This is the first time we have ever seen FGM addressed at the very highest level.' Photograph: Graham Turner for the Guardian

A major inquiry has been launched into female genital mutilation (FGM) to uncover why there has not been a single prosecution in the UK since it was made a criminal offence, and to try to bring an end to the illegal practice.

After sustained pressure from campaigners who have called for the the government to take action, the home affairs select committee will examine if the current legal framework is fit for purpose and look at why there has not been a prosecution in three decades.

Following a report from the Royal College of Midwives, which identified more than 66,000 victims of FGM in England and Wales and warned that 24,000 girls under the age of 15 were at risk, the committee will probe the systems for collecting and sharing information on FGM, which campaigners have stated is patchy in places and non-existent in others.

A petition from campaigner Leyla Hussein states that the battle to elimate FGM is failing because "multi-agency guidelines are not statutory, implementation at local authority and NHS level is disjointed, funding is minimal, and nobody is monitoring or holding anyone to account". It has garnered more than 94,000 signatures following her programme The Cruel Cut.

Efua Dorkenoo, head of Equality Now's FGM policy and a long-time campaigner, hailed the news as a significant breakthrough.

"It is brilliant news and I very much welcome the inquiry from the home affairs select committee," she said. "This is a significant move as it is the first time we have ever seen FGM addressed at the very highest level."

She called on the committee to take on board the recommendations made by the Royal College of Midwives report, which called for NHS workers to gather information on FGM and share it with police, education and social care workers as well as treating FGM as child abuse. It asked that health workers who detect evidence of FGM treat it as a crime and inform the police.

"We need a joined-up system with a focus on protection, prevention and prosecution with real leadership and accountability," said Dorkenoo. "If we do not get that then girls will continue to be mutilated. Without leadership from the top it will just be a talking shop."

Nimco Ali, who founded the anti-FGM charity Daughters of Eve, welcomed the news but said without the backing of the Department for Education the issue could not be effectively tackled. "The DfE is refusing to engage with this issue at all, and I would call on Michael Gove to speak to young people affected and make the issue of FGM and violence against women and girls part of the curriculum."

The committee will look at current awareness-raising efforts, the barriers to intervention, and how police, health, education and social care professionals work together. It will also look at the services that are available to girls and women who have suffered FGM and how they can be improved.

The chair of the committee, Keith Vaz, said: "It is shocking that 28 years on from female genital mutilation first being made a criminal offence, there has not yet been a successful prosecution in the UK. The committee's inquiry will seek to find out why this is the case, as well as considering what more needs to be done to protect at-risk girls.

"We would welcome evidence from those affected by this hideous crime as well as those whose responsibility it is to protect them."

The minister for crime prevention, Norman Baker, said the government was taking a firm line on FGM and was working with charities on on awareness-raising and with the DPP to secure convictions: "There is no justification for female genital mutilation – it is child abuse and it is illegal. I am determined we do all we can to bring perpetrators to justice," he said. "The law in this country applies to absolutely everyone and political or cultural sensitivities must not get in the way of preventing, uncovering and prosecuting FGM.

"Nor is there any religion which condones FGM so it's important that we get to the hard-to-reach communities who believe that their religion demands, or sanctions, FGM."