February 6th marks the International Day of Zero Tolerance of Female Genital Mutilation (FGM). On this day, the International Federation of Gynecology and Obstetrics reaffirms its longstanding position that female genital mutilation is a harmful practice and that all girls and women deserve to live free from all forms of violence, including FGM. Health care providers have a unique role in working towards the elimination of FGM and ensuring that all women and girls enjoy the full extent of human rights and freedoms.
What is it?
Female genital mutilation is defined as the ‘partial or total removal of the female external genitalia or other injury to the female genital organs for cultural or other non therapeutic reasons
The Magnitude of the Problem
Approximately 140 million women and girls worldwide have undergone FGM and each year about 3 million more are added to this number. FGM is most common in parts of West, East and Central Africa, some parts of the Middle East and South Asia; there is significant prevalence in about 30 countries.
Of the millions of girls who undergo FGM every year, the majority are under the age of 15. In some parts of the world such as Yemen, the practice is usually performed on infant girls under 2 weeks of age. In countries such as Mali and Ethiopia it is performed on girls under the age of 5, fifty percent of the time. In the majority of FGM practicing countries such as Egypt and Indonesia, 90 percent of the girls and women are between the ages of 5 and 15.
International Efforts to Eliminate FGM
In 2008 the United Nations released a joint statement supporting the elimination of female genital mutilation and calling for its eradication within a generation. Ten agencies were in support of this statement including UNIFEM, UNICEF, UNFPA, UNECA and UNHCHR, UNESCO, UNAIDS, OHCRH and WHO. Their stance is echoed by numerous NGOs and professional health and rights association. Following this joint statement was a resolution by the 61st World Health Assembly denouncing FGM as a violation of human rights and a barrier in the achievement of the Millennium Development Goals. Considering that FGM is almost always performed on minors, it is a clear violation of the rights of the child who cannot provide consent. It also violates the right to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment and the right to life. The resolution calls on member states to accelerate actions towards the elimination of the practice including the enactment and enforcement of legislation to protect women and girls from FGM and all forms of violence, the development of social and psychological support services as well as for greater research, guideline development and community based action regarding FGM.
At the National and Community Level
Many countries worldwide have criminalized FGM. This includes countries with a high prevalence of FGM as well as countries who host immigrants and refugees who may wish to have the procedure for their daughters.
Considering the cultural meaning of the practice, the creation of ‘alternative’ rights of passage has developed at the community level in an attempt to confer the cultural importance of the practice without physically harming the girls. These have included weekend retreats with song, dance and lessons from elder women about becoming a woman and the roles and responsibilities that accompany this. Safe houses, for girls wishing to run away instead of undergo the procedure have been set up in some communities.
Increasing attention is needed in how prevention and the eventual elimination of the practice are tackled. Some communities have demonstrated troubling responses to the increased public pressure to eliminate the practice. This has included medicalisation of FGM, in an attempt to mitigate the negative health consequences and quell opposition while maintaining the practice. It is also an attempt to legitimate the practice by involving the health care community. In some places FGM is being carried out earlier than before to avoid girls' protests. Another unfortunate result of criminalization has been the movement of the practice underground, meaning less access to medical attention when complications arise.
The Role of Health Care Professionals and their Associations
FIGO has taken a strong stance against the practice of FGM. The Montreal 1994 FIGO General Assembly Resolution on FGM encourages FIGO’s societies to urge national governments to sign onto the international human rights agreements condemning the practice and to support the work of national authorities, NGOs and intergovernmental organizations working to eliminate the practice. The FIGO committee for ethical aspects of reproductive health has two guidelines opposing FGM, the most recent concerning medicalisation (London, 2006). FIGO continues to recommend that individual obstetricians and gynecologists explain and educate about the consequences of FGM while supporting community members opposing its continuation. Organizations and individuals are further encouraged to support research on the prevalence and effect of the practice while opposing any attempts to medicalise the procedure or allow its performance in health establishments by health professionals.
Due to international migration, health care providers all over the world are caring for women with female genital mutilation. Research by WHO has shown that these women have an increased risk of adverse outcome during childbirth, notably perinatal death. It is important for health care professionals to be aware of the practice, its variable effect on genital anatomy and function, as well as the cultural significance of the tradition. Caring for all women with sensitivity and respect is a part of protecting women’s sexual and reproductive rights and health. While opposition to the practice is important, the utmost sensitivity and respect in treating women who have already undergone the procedure is part of providing quality care.
The Health Consequences of FGM
· Severe pain
· Urine retention
· Ulceration of the genital region
· Injury to adjacent genital tissue
· Recurrent urinary tract infections
· Abscesses in the vulva
· Chronic pain and infection
· Pelvic Inflammatory Disease
· Adverse psychological and sexual consequences
· Increased risk of perinatal death