Female genital mutilation/cutting towards abandonment of a harmful cultural practice

Transcription

1 Australian and New Zealand Journal of Obstetrics and Gynaecology 2014; 54: DOI: /ajo Review Article Female genital mutilation/cutting towards abandonment of a harmful cultural practice Nesrin VAROL, 1,2 Ian S. FRASER, 1,2 Cecilia H. M. NG, 1 Guyo JALDESA 3,4 and John HALL 5 1 Queen Elizabeth II Research Institute for Mothers and Infants, University of Sydney, Sydney, Australia, 2 Royal Prince Alfred Hospital, Sydney, Australia, 3 Department of Obstetrics and Gynecology, University of Nairobi, Nairobi, Kenya, 4 Kenyatta Hospital, Nairobi, Kenya and 5 School of Medicine and Public Health, University of Newcastle, Newcastle, Australia Globally, the prevalence of, and support for, female genital mutilation/cutting (FGM/C) is declining. However, the entrenched sense of social obligation that propagates the continuation of this practice and the lack of open communication between men and women on this sensitive issue are two important barriers to abandonment. There is limited evidence on the role of men and their experiences in FGM/C. Marriageability of girls is considered to be one of the main driving forces for the continuation of this practice. In some countries, more men than women are advocating to end FGM/C. Moreover, men, as partners to women with FGM/C, also report physical and psychosexual problems. The abandonment process involves expanding a range of successful programs, addressing the human rights priorities of communities and providing power over their own development processes. Anecdotal evidence exists that FGM/C is practised amongst African migrant populations in Australia. The Australian Government supports a taskforce to improve community awareness and education, workforce training and evidence building. Internationally, an African Coordinating Centre for abandonment of FGM/C has been established in Kenya with a major global support group to share research, promote solidarity, advocacy and implement a coordinated and integrated response to abandon FGM/C. Key words: Australia, female genital mutilation, footbinding, infibulation, Millennium Development Goals. Introduction Female genital mutilation/cutting (FGM/C) refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons. There are four types of FGM/C (Table 1). 1 In type III or infibulation, the vaginal entrance is sutured with unsterile suture-like material, typically without analgesia. Complications from this procedure include transmission of viral infections such as HIV and hepatitis, septicaemia, tetanus, haemorrhage and shock. Injury to adjacent organs, such as rectum and urinary tract, can occur during the cutting (Figure 1). Table 1 WHO Classification of FGM/C 1 Type I Type II Type III Type IV Partial or total removal of clitoris and/or prepuce Partial of total removal of clitoris and labia minora, with or without excision of labia majora Infibulation. Excision of part or all of external genitalia and stitching of the two cut sides together to varying degrees All other harmful procedures to female genitalia for non-medical purposes, for example pricking, piercing, incision, stretching, scraping and cauterization Correspondence: Dr Nesrin Varol, Queen Elizabeth II Research Institute for Mothers and Infants, University of Sydney, NSW 2006, Australia. nesrin.varol@sydney.edu.au Received 3 June 2013; accepted 3 March Figure 1 Urinary tract obstruction in an infant following FGM/ C (Courtesy: Assoc Prof Moustapha Toure, Mali Hospital, Bamako, Mali). The urethra was injured in this infant, causing obstruction, hydronephrosis and kidney damage The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology

2 Approaching abandonment of FGM/C The World Health Organization (WHO) estimates that more than 125 million girls and women in 28 African countries have undergone FGM/C, with three million at risk each year. FGM/C is also prevalent in some countries in Asia and the Middle East, and in migrant communities from these countries in Europe, United States, Australia and New Zealand. 2 Although FGM/C has persisted for centuries, as it has deep-seated cultural and perceived religious roots, there is evidence that it is on the decline with girls less likely to be cut today compared to their mothers. 2 Of the United Nations (UN) list of the world s 49 least developed countries, 33 are part of the African continent. Sub-Saharan African nations continue to have some of the highest maternal and infant mortality rates in the world. It is estimated that an additional 10 to 20 babies die per 1000 deliveries as a result of FGM/C. 3 A WHO landmark prospective collaborative study of 30,000 women across 28 obstetric centres in six African countries showed women with FGM/C type III had a 30% higher risk of caesarean section and a 70% increase in postpartum haemorrhage compared with those without FGM/C. The perinatal mortality rate was 15%, 32% and 55% higher in women with FGM/C types I, II and III, respectively. 4 Furthermore, newborns were 66% more likely to require resuscitation if their mothers had FGM/C type III. These data reflect outcomes for women delivering in healthcare facilities where staff have experience in caring for women with FGM/C. We predict the outcome for women delivering in remote, rural areas would be worse. Other preventable complications associated with FGM/ C may include obstetric fistula and infertility. A multicentre case control study in Sierra Leone is examining the link between FGM/C and obstetric fistula. 5 Pilot data from this study suggests an association between these events. Keloid formation following FGM/C is common and can lead to obstructed labour (Figure 2) and hence secondary fistula development. 5 FGM/C was associated with infertility in a study of 99 women with primary infertility in was Sudan. 6 The anatomical severity of FGM/C, rather than closure of the Figure 2 Obstructed labour in a woman with infibulation (Courtesy: Assoc Prof Moustapha Toure, Mali Hospital, Bamako, Mali). vulva per se, was positively associated with infertility in these women. Women with extensive FGM/C and infertility were equally likely to have normal laparoscopy findings or adnexal pathology. FGM/C may result in microbial colonisation or low-grade inflammation of the reproductive tract adversely impacting on fertility. 6 FGM/C is the epitome of gender inequality and directly affects the attainment of the first six Millennium Development Goals 7 by its impact on health and mortality of women and children, HIV transmission, 8 and girls inability to continue schooling. The medical repercussions of FGM/C have substantial health care costs, adding to the health care budget of some of the world's poorest countries. A WHO study estimated that 2.8 million 15-year-old girls in six African countries would lose about 130,000 years of life secondary to complications related to obstetric mortality from FGM/C. It is estimated that I$ 2.50 and 5.82 (international (purchasing power) dollars adjusted for the cost of living in each country) are required for prevention programs for FGM/C types II and III, respectively. These costs would be offset by the economic saving of managing obstetric complications from FGM/C. 9 Abandonment of FGM/C is possible and can be a reality. Analogous to this was the harmful traditional practice of footbinding, which originated in Imperial China and placed status and control on a woman s sexuality. Anti-footbinding campaigns and Chinese reformers were largely responsible for its ultimate abandonment within a generation and lessons can be learnt from this. 10 FGM/C in Australia The frequency with which FGM/C is being performed on girls in Australia or in their African country of origin during a family visit overseas is unknown. FGM/C has been illegal in Australia since In 2012, four people were charged in New South Wales for being involved in performing FGM/C on two girls aged six and seven. 12 A survey of 385 RANZCOG Fellows, Diplomates and Trainees and FGM/C prevention and education workers in Australia and New Zealand cited anecdotal evidence that FGM/C is being performed in these countries. 13 Twenty-one percent of RANZCOG respondents had been asked to resuture following delivery and 3% had done so more than once. Two out of 385 respondents had been asked to perform FGM/C on a baby, girl or young woman. The authors report that these figures may be an underestimation due to the low survey response rate of 19%. Many African migrants from countries where FGM/C is practised, are resettled in rural Australia where they may not be able to access trained clinicians. 13 Unfamiliarity in caring for a woman with FGM/C during and following labour was highlighted in the survey responses. Staff are unable to perform vaginal examinations to assess the progress of labour for women with FGM/C type III and are more likely to proceed to a 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 401

3 N. Varol et al. caesarean section. They also do not have the knowledge and skill to perform an anterior episiotomy or de-fibulation in labour. A discussion about de-fibulation during pregnancy and the right and choice not to be re-infibulated following delivery, will allow for a better outcome of childbirth. Interviews with African women with FGM/C about their birth experiences in Australia reveal they were concerned about the cultural competence, experience and training of Australian midwives and obstetricians. The African women often needed to explain to Australian healthcare professionals how FGM/C is managed during labour in their countries of origin. 14 Developing guidelines for Australian doctors and midwives will improve understanding of how FGM/C affects individual women and their partners. This knowledge may then be used to counsel women not to request or perform FGM/C on their daughters. Currently limited data are available on the physical and psychological consequences of FGM/C in African migrant women in Australia. 15 A study of 66 African migrant women in the Netherlands revealed that 16% suffered from post-traumatic stress disorder about the FGM/C procedure and a third from depression and anxiety. The study also highlighted that psycho-pathological problems were related to the severity of FGM/C, age, clarity of memory and use of drugs at the time it was performed. 16 Auburn Hospital in Sydney and the Royal Women s Hospital in Melbourne have established Women s Clinics and training workshops with culturally sensitive guidelines for healthcare professionals focusing on obstetric care and education of women, their partners and communities. De-fibulation counselling and procedures form part of their services. FGM/C imposes considerable financial costs on health care systems in addition to loss of life from haemorrhage, infection and obstetric complications, psychological trauma and reduced economic productivity. 9,11 Further research towards understanding the obstetric outcomes of women who have experienced FGM/C in the Australian context is important. Not only will it improve quality, accessibility and acceptability of maternal health care for these women and their babies, but also lead to significant cost reduction and decreased burden on the Australian healthcare system. Why FGM/C continues FGM/C is considered a violation of human rights of the child on whom it is performed. 17 It violates the right to life, the right to be free of torture or cruel, inhuman or degrading treatment, the right to equality and nondiscrimination on the basis of gender, amongst others. Consent to the procedure is never obtained from the child. These rights are guaranteed in treaties adopted by the UN, the Organisation of African Unity and other international agencies. 17 While FGM/C can be considered an act of de facto violence, it is imperative to understand that culturally it does not carry in any way the intention of violence on the part of the operator. Hence, some communities may not accept the categorisation that FGM/C is an abuse of human rights. Continuation of FGM/C is motivated by a complex mix of socio-cultural factors, of social acceptance, peer pressure, fear of exclusion from resources and opportunities as a young woman and marriageability. 18,19 Practised as a matter of social convention, it is linked to different socio-cultural perceptions associated with local definitions of gender, sexuality and religion. Reasons can vary in different communities. FGM/C may be performed for perceived necessity for spiritual cleanliness, for family honour and to maintain premarital virginity and marital fidelity. Effective punitive social and community measures are in place for nonconformity. FGM/C may also be a rite of passage, a transition from childhood to womanhood. 5 Male attitudes to FGM were investigated in a study that interviewed 59 men in Sudan, 20 Social acceptance or social pressure, followed by tradition, were the main reasons stated by men who preferred to marry a women with FGM. Respect from the community is intricately linked to being married to a woman of virtue. 20 Social obligation or normative expectations are also believed to be responsible for the wide variation in prevalence and support for FGM/C among different ethnic groups in many countries. 2 Even though no religion condones FGM/C the belief it is a religious requirement by some local religious leaders and communities, fuels its continuation. In Mali, nearly two-thirds of girls and women and about 40% of boys and men believe FGM/C is required by religion. 2 In Egypt, Sudan and Senegal, Christian and Muslim leaders have been playing a crucial role in helping to abandon this practice. They have condemned the link between Islam and FGM/C, declared it violates women s dignity and have been promoting the uncut girl as happy and healthy. 19,21,22 Another possible reason is the reality and fear of sexual violence against girls, particularly in communities where infibulation is practised, as it precludes vaginal penetration or makes it difficult. Evidence exists linking FGM/C and higher incidences of intimate partner violence (IPV). Demographic and Health Survey data from Mali from approximately 8000 women aged examined the link between FGM/C and multiple forms of IPV. Women with FGM/C were more likely to experience physical, sexual or emotional IPV, with odds ratios of 2.9, 3.2 and 2.3, respectively. The more severe the type of FGM/C, the more likely that a woman had experienced IPV. Women with the most severe type of FGM/C had an approximate nine times increased risk of IPV. 23 Mothers may subject their daughters to FGM/C to protect them, to secure good prospects of marriage, to ensure acceptance in the community and for economic security The Royal Australian and New Zealand College of Obstetricians and Gynaecologists

4 Approaching abandonment of FGM/C Lessons from footbinding There is an analogy between FGM/C and footbinding in China. Both have controlled female sexuality and ensured female chastity and fidelity. Both have been required for family honour and good marriage, have been performed on young girls and sanctioned by tradition. 25 In footbinding the arch and toes were forcibly broken without analgesia, then tied with bandages, leaving the girl with severe pain. If the girls did not die from septic shock, they were at later risk of fracture of the hip or other bones and many were unable to walk properly. 10 Anti-footbinding campaigns were led by the urban upper classes in China and the practice ceased within a generation by the s. The Anti-footbinding Society lobbied support from elite men 26 and advocated for the education of girls. 27 When mothers accepted the assurance that men preferred to marry women with natural feet, they were willing to abandon this practice. 10 The benefit of the cultural practice was removed: it caused prejudice and disadvantage, became a liability and a prosecutable offence. The Anti-footbinding Society ensured they upheld the good values of women associated with this tradition, whilst denouncing the practice. The media often portrays communities that practice FGM/C as barbaric and abusive. Women with FGM/ C must not be stigmatised and do not want to be seen as victims. In the endeavour to accelerate abandonment of FGM/C it is important not to portray these women in a manner that is contradictory to the cultural values ascribed to them. It is confusing, hurtful and injures their dignity. Moreover, it ignores their suffering and pain and can result in women themselves remaining staunch supporters of harmful practices. The role of men The experiences and role of men in FGM/C have not been adequately addressed in previous studies and may be an important key to bringing about Mothers may abandonment. As discussed previously, an important reason FGM/C continues in many communities is marriageability of the girls. Men may play a passive role in approving FGM/C by refusing to marry uncut women or an active one by actually initiating the practice. In Eritrea, for example, mothers of daughters who had undergone FGM/C, reported that it was the fathers (28%) and grandparents (45%), particularly grandfathers and community leaders, who had instigated the process. 28 In a survey that describes the experiences of 59 Sudanese men who had a partner with FGM/C, 63% of those interviewed expressed difficulty with vaginal penetration, wounds or infections on the penis and psycho-sexual problems. They also described that their awareness of the suffering of their wives during sexual intercourse impacted negatively on their own sexual satisfaction. Most notable was the finding that men perceived their wives suffering as their own problem. Most young men stated that they would have preferred to marry a woman without FGM, even though they were married to women who had undergone FGM. 20 This is in contrast with findings from an Ethiopian study that men prefer marriage to women with FGM. 29 This preference is presumed, as only women were interviewed. In fact, girls and women consistently underestimate the percentage of boys and men who want FGM/C to end. 2 With the lack of communication between men and women regarding this practice, false beliefs and expectations by both genders are hence perpetuated. 20 Cultural practices, when moving into a new society, can often be discarded or modified, and new ones adopted according to what is valued by the new society and is considered personally most beneficial. A study of attitudes towards FGM/C among Somali immigrants in Oslo, Norway, revealed that uncut girls were much more likely to attract boyfriends and get married than girls who had been subjected to FGM/C. 30 Approximately 60% of the Somali male immigrants in Norway preferred to marry uncut women. Involving men and boys in education campaigns is critical if we are to see the end of FGM/C. Men need to be able to communicate that they would like to marry uncut girls. Hence, families can begin to recognise that their daughters will be distinctly disadvantaged if they have them cut. 31 The Norwegian study also reported that 70% of these migrants supported the discontinuation of all forms of FGM/C and 81% did not intend to subject their daughters to FGM/C. The majority of those who supported FGM/C had been living in Norway for <4 years. 32 This small rate of support in Norway is in contrast with the FGM/C rate of 98% in Somalia, 33 suggesting that change can probably be brought about within a generation if the benefit of a tradition declines. Addressing communities priorities Women and girls in sub-saharan Africa endure many human rights abuses in addition to FGM/C, such as lack of access to clean water, food security, health services and education, child marriage, and sexual violence. If these issues can be addressed and economic independence for women becomes a reality, they would no longer have to depend on FGM/C to ensure marriageability and for livelihood. Systematic evaluations demonstrate that prevention programs resulting in significant and permanent change in deep-seated socio-cultural practices almost always involve members of the local community in addition to local and global involvement of governments. 18,34 38 The most successful programs have been those where change comes from within and is embraced by the community. 39 They have been developed in accordance with human rights principles and gender equality, and are non-judgmental and non-coercive. Programs are more successful if they are collaborative, that is with as opposed to doing to others. 40 An environment is created allowing people to question 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 403

5 N. Varol et al. stereotypes, social norms and traditional harmful practices, a necessity to facilitate and support change. 19 Increasingly, individuals and local communities in a number of countries are questioning the value of FGM/C. Many would prefer, circumstances permitting, not to subject their daughters to the cutting. 19 It is important for communities to be given the power to voice their problems and make their own decisions, and have the right to organise themselves. They are able to see that the development process is transparent and addresses their needs. The intervention program of the non-governmental organisation Kembatti Mentti Gezzimma (KMG) Ethiopia is based on these principles. 19 The abstract concepts of human and women s rights were adapted to existing community understanding and needs. KMG implemented a number of community development projects in health, education, finance and the environment. These raised their credibility in the community and established trust, which allowed the introduction of awareness-raising communication and training of gatekeepers of traditional practices to bring about change in their community. 19 Where to from here? There is a great need for the demonstration of feasibility and for understanding the impact of various interventions. Continuing efforts are required to monitor policy development, research and interventions of programs to create synergy between the different approaches, which have been adopted. There also has to be awareness that programs will have differing impacts in different cultures. Conversations between men and women affected by FGM/C are crucial to break the relative silence of this private and sensitive issue, so that false expectations do not continue to be perpetuated. Programs that foster this dialogue and open the practice to public scrutiny in a respectful way may create better support to abandon FGM/C. 2 In April 2013, the Australian Government launched a national coordinated strategy to support education, law enforcement and existing international efforts, and improve and/or establish health services for these children and women in Australia. 41 To this end, Australia has been pivotal in its establishment of an African Coordinating Centre for Abandonment of FGM/C (ACCAF) at the University of Nairobi, Kenya, with a consortium of UN bodies, research institutions and Ministries of Health. It is envisaged that it will centralise research and prevention programs, promote solidarity and implement a well-funded, coordinated and integrated global response for the abandonment of FGM/C. Conclusion FGM/C is a global issue that affects both women and men. There is anecdotal evidence that it is performed on children in Australia. FGM/C causes significant physical and psychological suffering to the affected women and girls, and has a negative effect within the health system. Many men and women are locked in a convention with beliefs that perpetuate false expectations. Men s experiences of complications of FGM/C and their views supporting the abandonment of this practice need further research and to be communicated to their communities. Research and advocacy towards ending FGM/C should include more programs that create space for communication between men and women. Advocacy by men and exposure to other cultures that do not practice FGM/C are important catalysts to its abandonment. Studies of African migrants reveal that support for FGM/C declines significantly when they move to countries that do not practice this tradition. The benefit of this practice becomes less, as many men prefer to marry girls who are not cut. Moreover, the pressure of social obligation is reduced. Change is also more likely to occur when priorities for development of communities are addressed first and trust is established. When efforts are directed at attainment of basic human rights and education of boys and girls, space is created for communities to discuss harmful traditional practices. Sustainable change occurs when the decision for abandonment comes from within and is embraced by communities. The successful abandonment of the Chinese practice of female footbinding teaches us the importance of highlighting and denouncing the harmful traditional practice and not placing blame on the women or the communities. Change towards abandonment needs to be through concerted efforts of communication, collaboration and understanding. These should be fostered between men and women of local communities that practice FGM/ C, in conjunction with governments and international organisations involved in the widespread efforts to abandon FGM/C. References 1 Sexual and Reproductive Health. 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