Female Genital Mutilation: A Taboo to the Islamic World and Efforts of WHO.

Vimu Ahuja

Author of this blog is a Practicing Advocate at Agra District Court

 Female genital mutilation (FGM) involves the partial or total removal of external female genitalia or other injury to the female genital organs for non medical reasons.

·      The practice has no health benefits for girls and women.

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

·     More than 200 million girls and women alive today have been cut in 30 countries in Africa, the Middle East and Asia where FGM is concentrated (1).

·         FGM is mostly carried out on young girls between infancy and age 15.

·         FGM is a violation of the human rights of girls and women.

·    WHO is opposed to all forms of FGM, and is opposed to health care   providers performing FGM (medicalisation of FGM).

·     Treatment of health complications of FGM in 27 high prevalence countries costs 1.4 billion USD per year.

Female genital mutilation (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 reasons.

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 belief that the procedure is safer when medicalized¹. WHO strongly urges health care providers not to perform FGM.
FGM is recognised 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.

                     Types of FGM
                     Female genital mutilation is classified into 4 major types.

·      Type 1:  this is the partial or total removal of the clitoral glans (the external and visible part of the clitoris, which is a sensitive part of the female genitals), and/or the prepuce/ clitoral hood (the fold of skin surrounding the clitoral glans).

·         Type 2:  this is the partial or total removal of the clitoral glans and the labia minora (the inner folds of the vulva), with or without removal of the labia majora (the outer folds of skin of the vulva ).

·          Type 3: Also known 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 clitoral prepuce/clitoral hood and glans (Type I FGM).

·          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 area.

De-infibulation refers to the practice of cutting open the sealed vaginal opening of a woman who has been infibulated, which is often necessary for improving health and well-being as well as to allow intercourse or to facilitate childbirth.

No health benefits, only harm

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 bodies. Generally speaking, risks of FGM increase with increasing severity (which here corresponds to the amount of tissue damaged), although all forms of FGM are associated with increased health risk.

Immediate complications can include:

·         severe pain

·          excessive bleeding (haemorrhage)

·         genital tissue swelling

·         feve

·          infections e.g., tetanus

·          urinary problems

·         wound healing problems

·         injury to surrounding genital tissue

·         shock

·         death.

Long-term complications 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 sealing or narrowing of the vaginal opening (Type 3) may lead to the practice of cutting open the sealed vagina later to allow for sexual intercourse and childbirth (de-infibulation). Sometimes genital tissue is stitched again several times, including after childbirth, hence the woman goes through repeated opening and closing procedures, further increasing both immediate and long-term risks;

·         psychological problems (depression, anxiety, post-traumatic stress disorder, low self-esteem, etc.);

Who is at risk?

FGM is 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 annually. More than 200 million girls and women alive today have been subjected to the practice , according to data from 30 countries where population data exist.¹
The practice is mainly concentrated 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 concern.

Cultural and social factors for performing FGM

The reasons why female genital mutilations are performed vary from one region to another as well as over time, and include a mix of socio-cultural factors within families and communities. The most commonly cited reasons are:

·        Where FGM is a social convention (social norm), the social pressure to conform to what others do and have been doing, as well as the need to be accepted socially and the fear of being rejected by the community, are strong motivations to perpetuate the practice. In some communities, FGM is almost universally performed and unquestioned.

·        FGM is often considered a necessary part of raising a girl, and a way to prepare her for adulthood and marriage.

·        FGM is often motivated by beliefs about what is considered
acceptable sexual behaviour. It aims to ensure premarital virginity and marital fidelity. FGM is in many communities believed to reduce a woman's libido and therefore believed to help her resist extramarital sexual acts. When a vaginal opening is covered or narrowed (Type 3), the fear of the pain of opening it, and the fear that this will be found out, is expected to further discourage extramarital sexual intercourse among women with this type of FGM.

·        Where it is believed that being cut increases marriageability, FGM is more likely to be carried out.

·        FGM is associated with cultural ideals of femininity and modesty, which include the notion that girls are clean  and beautiful after removal of body parts that are considered unclean, unfeminine or male.

·        Though no religious scripts prescribe the practice, practitioners often believe the practice has religious support.

·        Religious leaders take varying positions with regard to FGM: some promote it, some consider it irrelevant to religion, and others contribute to its elimination.

·        Local structures of power and authority, such as community leaders, religious leaders, circumcisers, and even some medical personnel can contribute to upholding the practice. Likewise, when informed, they can be effective advocates for abandonment of FGM.

·        In most societies, where FGM is practised, it is considered a
cultural tradition, which is often used as an argument for its
continuation.

·        In some societies, recent adoption of the practice is linked to copying the traditions of neighbouring groups. Sometimes it has started as part of a wider religious or traditional revival movement.

 A financial burden for countries

WHO has conducted a study of the economic costs of treating health complications of FGM and has found that the current costs for 27 countries where data were available totaled 1.4 billion USD during a one year period (2018). This amount is expected to rise to 2.3 billion in 30 years (2047) if FGM prevalence remains the same – corresponding to a 68% increase in the costs of inaction. However, if countries abandon FGM, these costs would decrease by 60% over the next 30 years.

International response

Building on work from previous decades, 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.
Progress at international, national and sub-national levels includes:

·        wider international involvement to stop FGM;

·        international monitoring bodies and resolutions that condemn the practice;

·        revised legal frameworks and growing political support to end FGM (this includes a law against FGM in 26 countries in Africa and the Middle East, as well as in 33 other countries with migrant populations from FGM practicing countries);

·        the prevalence of FGM has decreased in most countries and an increasing number of women and men in practicing communities support ending its practice.

Research shows that, if practicing communities themselves decide to abandon FGM, the practice can be eliminated very rapidly.
In 2007, UNFPA and UNICEF initiated the Joint Programme on Female Genital Mutilation/Cutting to accelerate the abandonment of the practice.
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 organisations. WHO supports countries to implement this strategy.
In December 2012, the UN General Assembly adopted a resolution on the elimination of female genital mutilation.
Building on a previous report from 2013, in 2016 UNICEF launched an updated report documenting the prevalence of FGM in 30 countries, as well as beliefs, attitudes, trends, and programmatic and policy responses to the practice globally.
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. The guidelines were
developed based on a systematic review of the best available evidence on health interventions for women living with FGM.

In 2018, WHO launched a clinical handbook on FGM to improve knowledge, attitudes, and skills of health care providers in preventing and managing the complications of FGM.WHO response In 2008, the World Health Assembly passed resolution WHA61.16 on the elimination of FGM, emphasising the need for concerted action in all sectors - health, education, finance, justice and women's affairs. WHO efforts to eliminate female genital mutilation focus on:

·        strengthening the health sector response: developing and implementing guidelines, tools, training and policy to ensure that health care providers can provide medical care and counselling to girls and women living with FGM and communicate for prevention of the practice;

·        building evidence: generating knowledge about the causes, consequences and costs of the practice, including why health care providers carry out the practice, how to abandon the practice, and how to care for those who have experienced FGM;

·        increasing advocacy: developing publications and advocacy tools for international, regional and local efforts to end FGM, including tools for policy makers and advocates to estimate the health burden of FGM
and the potential public health benefits and cost savings of preventing FGM.

^1. Female Genital Mutilation/Cutting: A Global Concern UNICEF, New York, 2016.