FEMALE GENITAL MUTILATION
CULTURAL SIGNIFICANCE, MEDICAL
COMPLICATIONS AND WESTERN CLINICIANS
The practice of female “circumcision,” or traditional female genital surgery, is simultaneously complex and controversial. Although some consider it a human rights infringement, others view it as an integral part of cultures in which it remained unchallenged for centuries. With more than 30,000 Africans entering the United States in the last decade, American clinicians are challenged with meeting African women’s health needs, as they are barraged with a debate about the ethics and politics of circumcision. There are significant medical sequel and public health ramifications of female circumcision; therefore most U.S. physicians probably would agree that programs to abolish it should continue. However, although there is ample media and political attention to this volatile issue, there is a relative dearth of practical, clinical information available to providers who care for circumcised women and their families. As African communities and advocates grapple with how to stop this practice, circumcised women need clinicians familiar with these surgeries, who will move beyond negative feelings they may have about the practice in order to treat women knowledgeably and with dignity. It is important to distinguish respect from un-reflective acceptance. However, blanket condemnation by health workers will not help families decide how to break a long-standing tradition by choosing not to circumcise their daughters. On the contrary, by unwittingly conveying revulsion toward circumcised women and children, providers may drive these families away from the health care they need.
Our objective is to understand and address the conflicts that occur when clinicians provide care to patients whose beliefs and practices differ from their own. We review the practice, cultural significance and medical complications of female circumcision, and offer sensitive clinical guidelines, illustrated by case examples, for caring for currently circumcised women (Survivors).
Many African women label this practice “genital mutilation,” believing “circumcision” to be deceptive. Other women do not consider their bodies mutilated and find the former term judgmental and inflammatory. We use the term “circumcision.” More neutral and more accurate terms now coming into use are traditional, or ritual female genital surgery. We review the practice, cultural significance and medical complications of female circumcision, and offer sensitive cultural guidelines, illustrated by case examples, currently caring for circumcised women. It is estimated that more than 200 million girls and woman alive today have undergone FGM in the countries where the practice is concentrated. Furthermore, there are an estimated 3 million girls awaiting FGM every year.
Circumcision happens between birth and 8 years of age, although occasionally up until the birth of their first child, but most girls are cut before they turn 15 years old. It is most prevalent on the African continent’s equatorial. It’s prevalence varies from over 90% in Somalia to less than 10% in Arabic nations.
Our objective is to understand and address the conflicts that occur when clinicians in North America whose beliefs and practices differ from that of immigrants or refugees.
15% of these surgeries result in infibulations
80% of women in Somalia and Sudan are infibulated
CLINICIANS AND NON-CIRCUMCISING CULTURES
We must curb a tendency of viewing behaviour as rational or irrational from a ratified clinical perspective. Rather, we may want to see behaviours within the context of patients’ lives and relationships. Although there is no single cultural explanation for female circumcision, there are several general points to make when attempting to place it in an understandable context.
In one study, more than 50% of health workers felt horror and revulsion, and over 30% were nauseated on first hearing about infibulation. Care providers are often unfamiliar with ritual practices and ways to approach the issue with their patients. Uncertainty and discomfort may cause a provider to avoid the issue on their patient, and the Clinicians who disagree with their patients’ choices face a conflict to three sets of values: a tendency to radicalize, or those of their profession, with a focus on the medical aspects of practices.
Clinicians can learn to separate their feelings about the practice from their obligation to care in a nurturing way for the survivors. Otherwise, judgemental attitudes may offend women who were circumcised (who probably had no say in the decision to be circumcised), inhibit further medical care, impair the trust, rapport necessary to discuss health issues and the potential harms of continuing the practice.
African immigrants and refugees in North America experience a marked discrepancy between their traditional culture and their new culture. In general, they have a strong reliance and value community affiliation over individualism, in Africa, a male family member’ permission is often necessary for decisions about reproductive health issues etc. The North American medical system positively values patient autonomy, at times excluding family members during private discussions. Community members or leaders may advice African immigrants about where and from whom to seek care, as well as the type of problems appropriate to bring to a medical encounter and News of a troublesome encounter with a specific provider or clinic may quickly spread through an entire community. In these small communities, interpreters have a significant social influence and for this reason, community members worry that the information will be circulated outside the encounter.
Even a well trained interpreter represents a third person in the medical encounter and diminishes the mental safety of a private and intimate provider-patient interaction. Certainly, family members may disagree with, or be embarrassed by, a woman’s concerns or questions and are inappropriate sources of interpretation. Some women may fear examinations if they believe that clinicians will react negatively to their circumcision, women are also offended by Western clinicians’ tendency to show physical findings to their colleagues. they expect the Doctor to know that they are modest, and do not want to be touched just so they can see how they are different.
Immigrant women see male providers who are unfamiliar with their culture, the interpreters as a challenge and they have been offended by physicians who, on first seeing their genitalia, asked if they had been in an accident or splashed with acid. They do not agree with some clinicians’ assumptions that all circumcision survivors have complications or need medical care. Working with the survivors, our experience has been that many of them whether excised or infibulated, have no complaints related to their altered genitalia, and do not prefer that special attention be devoted to this issue, they may not understand why, medicalize circumcision, which they consider a tradition, not a medical procedure. Many African women are quite sophisticated, although rural and poor women may have little reproductive health education, or experience with gynecological examinations
"I had the foreskin on my clitoris removed as a baby, just like my brother. Why does everyone say it is so terrible and that I should have problems from it?"
HEALTH WORKERS AND UNTRAINED TRADITIONAL MEDICINE
Although health workers may circumcise the female using aseptic technique, medically untrained persons usually perform circumcisions without anesthesia in non-medical settings. Circumcisers may be skilled in traditional medicine, but their lack of training in surgery, their poor equipment, and the fact that the survivors may struggle, all suggest that it is difficult to be precise in an excision. Some women vividly recall their circumcision as a traumatic and painful experience, others have no memory of the procedure however, may recall only as a celebration.
“I want doctors to know that the way I look is normal for me.”
UNDERSTANDING CULTURAL PRACTICES AND TRADITIONS
Until recently in the societies in which it is practiced, circumcision has been seen as a necessary condition of life. The concept of female (and male) circumcision, with many traditions, can be invisible until people are forced to examine it. Circumcised female genitalia are considered normal to some Africans, just as circumcised male genitalia are normal to North Americans. A woman may desire circumcision to be marriageable, or chaste, for aesthetics, or to conform to tradition. Reasons for deeply rooted traditions are often difficult to articulate, and therefore are easily discounted, although many treat female genital surgery as a singular process affecting millions of women, it is not a homogeneous practice. The types of surgeries and rationales behind them are as diverse as the people that practice them, as with all traditional beliefs and practices of culturally diverse communities, it is important not to overgeneralize information learned from one group or community, but to learn from each community the significance of a practices.
ELEVATING THE ROLE OF WOMEN AND CULTURAL CHANGE
Efforts to elevate the role of women in African society will most likely include a discussion of ritual genital surgery, and respecting choices as well, as they may not consider it the central issue of inequality. Africans must debate the timing and framing of social change in Africa within the context of their families and neighbourhoods. The modification or elimination of ritual genital surgery depends on the opposition by families, religious, and community leaders/elders, not outsiders, however well intentioned.
Finally, although these practices probably have their origins in patriarchal authority, women are responsible for their day-to-day perpetuation. Woman who rebel against a community in which circumcision in uniformly practised by not circumcising their daughters may endanger their family’s social and economic support systems, making circumcision the safer of her sub-optimal choices. “Hence the paradox, the victims of the practice are also its strongest proponents,” according to the World Health Organisation report, men and women together create social expectations and resist change. Most of African people acknowledge that where they come from it is the natural practice of our people.” We must frame efforts to deter circumcision within the larger family and community that will be affected by, and respond to, a woman’s decisions. Women may fear the pain of defibulation, or the possible discovery of by their husbands that there was an accidental disruption of the circumcision, which could result in social humiliation and familiar disgrace.
PHYSICAL AND PSYCHOLOGICAL SEQUELAE
Dyspareunia may occur from difficult penetration, scarring and mental trauma. Anxiety and phobic behaviour may as well occur, as some women psychologically re-experience the pain and trauma of the procedure and its complications. however, the psychological sequelae are not well elucidated and may deserve further attention. Many refugees who arrive in North America faced war, rape, torture, starvation, loss of families, homes, their way of life, and they experience cultural shock. They need to recover from the trauma of war relocation in their new countries, where they are able to obtain homes, jobs, food, support for their family members who are left behind, in their countries of origin and many expatriates plan to return to their country of origin, and they base decisions for themselves and their families on how these choices will be viewed “back home”. For many women, circumcision is a source of pride, feeling a sense of belonging and sense of a community, and it is widely accepted and expected.
When the CEO of Great Lakes Networking Society while on the environmental project tour to Mt. Elgon, asked, “Why, this practice happens to girls, some women and not only men?” She was told that it was a belief that girls/women are “cut” in order to stop them from being sexually active, they are prepared for marriage, the perpetuation of FGM is largely attributed to culture with beliefs that those who do not undergo the cut cannot grow to become real women, and are regarded as small children who smell, as well they face lots of ridicule from members of their communities who taunted them for not being whole if the did not undergo the practice. The procedure ranges from removal of all/ or part of external genitalia and may lead to a litany of health issues, from urination problems, cysts and infections to sever bleeding, infertility or complications during childbirth. The UN estimates more than 125 million girls and women are living with the often-horrific consequences of FGM. Research indicates that complications during pregnancy and childbirth are the second cause of maternal deaths for girls between the ages of 15 and 19. FGM happens to be one of the greatest contributors of these complications and when measure are not taken, we are yet to experience even greater consequences.
CHALLENGES AND SOLUTIONS
In 2016, UNICEF pointed out that most girls undergo FGM before the age of 15. The act contributes significantly to high teenage pregnancies which is currently a menace across the continent. In 2011, all forms of FGM was criminalized in Kenya and the Anti-FGM Board set up to help combat the problem. While the constitution does not categorically refer to FGM, in an article 53 in states that every child should be protected from abuse, neglect, harmful cultural practices or any for of violence.
We all need to come up with sustainable solutions for girls and women in countries that this practice takes place. “It is evident that criminalization alone cannot end FGM, and survivor’s memory of the ordeal lives fresh in them after having witnessed the horror decades back. The World Health Organization reports that globally over 200 million girls have undergone FGM. In Kenya the regions of Garrisa, Masai-land, Samburu, Mt. Elgon, Kisii lead in the practice. These numbers pose a great challenge even as the UN embarks on empowering women through SDG 5 and 3. Kenya ranks 17th out of countries leading in the practice of FGM. Without progress this will translate to an increase in the number of girls forced into early marriages and even more reports of young pregnant girls who are considered women once they are cut.
Clinicians need to establish trust and dialogue with communities, once that is done, then they may receive requests to perform genital surgeries on children. Clinicians have a duty to inform families who want to circumcise their daughters, or who are from an area with a high prevalence of circumcision, about the complications of these practices. The physician can explain that to perform these surgeries on minors is illegal in North America, and is currently considered, by many, to be a form of child abuse. As with all behaviors health workers try to discourage, however, providers should support families, with sensitivity and without sensationalism, or risk a backlash of secrecy and mistrust.
The strategy of medicalizing ritual genital surgery and trying to eradicate it as if it were a disease, without recognising the larger socio-cultural context of which it is but one part, will be unsuccessful. It will continue until societies that practice it decide the practice is damaging to the welfare of women. Only efforts to improve the social and economic status of women, and education from within communities, can alter this practice. In a collaborative effort between health workers, education, dialogue, and conversations, the East Africans in Canada, for example, 72% of women reported having changed their attitudes from pro- to anti-circumcision. This is a different culture; things will probably change.” Refugees may adhere to traditions to remain part of the culture and country to which they hope to return. Many women fear uncircumcised children will not be part of their cultural lineage, will have genitalia considered unclean or ugly, and will not be protected from external and internal pressures to be inappropriately sexually active, without a chastity belt of flesh, but other women are eager to stop the practice. Both groups of women will need the support of community members and clinicians in initiating this cultural change.
In conclusion, clinicians face a challenge when providing care to patients with beliefs and practices that differ from their own. The current Western view of female circumcision as barbaric and primitive has undoubtedly influenced clinicians’ attitudes toward circumcised women. These factors contribute to African women’s feelings of being misunderstood and suboptimally treated by North American health care providers. Physicians should understand the medical complications and cultural context of circumcision, and clarify their own views about the practice and the patients if they are to offer quality care to circumcised women. Partnerships between clinicians and communities will promote communication and optimal care.
DEFINTIONS
: complete excision of the clitoris, labia minora, and most of the labia majora followed by stitching to close up most of the vagina
: difficult or painful sexual intercourse
: a condition which is the consequence of a previous disease or injury.