As the NSPCC launches the first helpline to protect young girls from female genital mutilation (FGM), the fact remains that there has not been a single conviction for this practice since it was outlawed in 1985. Charlotte Brazier presents the medical realities of this illegal practice which make it abuse, and not just a cultural custom.
Photo by Amnon Shavit (Wikimedia Commons)
An estimated 86,000 girls and women in the UK could be living with the effects of FGM, which is defined by the World Health Organisation (WHO) as: ‘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 performed without anaesthetic, and is carried out in 28 African countries, the Middle East and South East Asia. Due to increased immigration, FGM has also spread to Europe, North America and Australia. Approximately 140 million girls and women worldwide are now living with the consequences of FGM, which can be divided into immediate and long-term.
The effects of FGM
Immediate effects can include haemorrhage, injury to adjacent tissue, scar formation, and, in extreme cases, even fatality. Long-term effects include: post-traumatic stress disorder, dermoid cysts, dyspareunia, fistulae and difficulty of penetration, amongst others.
Rachel Johki, a midwifery lecturer at the University of Sheffield and a senior midwife on the Labour Ward at the Jessop Wing, Sheffield Teaching Hospitals NHS Foundation Trust, thinks understanding the effects of FGM requires compassion on behalf of medical staff.
“It is important to understand that the effects of FGM are not just physical,” she said. “The procedure can also have a long-term psychological impact on the girls, who are usually between the ages of four and 12 when it takes place.
“FGM very rarely takes place in a hospital, and instead is carried out in a hut by an untrained midwife, with several villagers present. The girls are forcibly restrained, which can sometimes lead to broken bones, and they are given no pain relief. Medical instruments are not used. Instead, the girls are cut with a piece of sharp rock, glass or razor blade.
“For girls from the UK, there is then the added stress of being taken from their home to have the procedure done in a country where it is still legal, such as India or Pakistan. Often they do not know that they will undergo FGM until the moment it is carried out, which can be terrifying.”
Tradition, not religion
Whilst religious belief is often cited as the main reason for FGM, there is no direct reference to the practice in the Qu’ran, and groups such as the Muslim Women’s League have actively condemned the procedure.
In many tribes, it is a cherished tradition, with communities believing that it will lead to a sense of acceptance in society. In some cultures, un-circumcised women are considered to be unclean, leading them to be ostracised by their peers.
It is also believed that FGM can help to prevent rape and promiscuity, or preserve virginity – leading to a higher dowry for the family upon marriage. In many cases, it is seen as a rite of passage to womanhood, and the families who facilitate or carry out the procedure genuinely believe that they are acting in the name of love.
Types of FGM
WHO (2008) has classified FGM into four main types. Type 1, alternatively known as ‘clitoridectomy’ or ‘Sunna’, in reference to the Prophet Mohammed, involves the excision of the clitoral prepuce and the excision of all or part of the clitoris.
Type 2 is the excision of the clitoris or the excision of all or part of the labia minora.
Type 3, also known as ‘infibulation’, involves the excision of part or all of the external genitalia, including the clitoris, and both labia minora and majora. Following this, the remaining edges of the labia are then sewn across the midline to leave a small posterior aperture (often no larger than a pinhead) for the passage of urine and menstrual blood.
Type 4 refers to all other non-medical genital procedures, including pricking, piercing and incising.
Incidences and prosecutions
In 2007, the Department of Health (DH) funded research carried out by The Foundation for Women’s Health (FORWARD), which identified that there were 66,000 women with FGM living in England and Wales, with a further 20,000 girls deemed to be at risk. In total, around 3,000 to 4,000 FGM acts may be performed annually in the UK.
FGM is illegal in the UK under the Prohibition of Female Circumcision Act 1985 and the Female Genital Mutilation Act 2003, which addressed the legal loophole of taking girls out of the country with the intention of facilitating the procedure. The maximum imprisonment sentence for aiding, abetting or carrying out FGM is 14 years.
However, whilst almost 160 FGM incidents were recorded in the 2008-9 British crime survey, there have been no convictions since it was outlawed in 1985. This compares to around 100 convictions in France, where all girls’ genitals are monitored until they are six years old.
In June 2013, UK MPs revealed that whilst there had been 148 referrals to the police over the last four years, only four had been passed to prosecutors, and none of these had led to charges.
The International Development Select Committee concluded that the UK must ‘put aside political correctness and adopt a far more robust, cross-agency approach’ in order to prevent at-risk girls from becoming victims of FGM.
Surgery and the law
Further legal implications arise regarding defibulation – the reversal of infibulation – and reinfibulation, which is the restoration of FGM following the defibulation procedure.
Defibulation involves opening the scar tissue that covers the vaginal introitus and urethral meatus in order to expose the underlying tissues. The incision, which is made along the midline, can also be extended to expose the clitoris and free any para-clitoral adhesions.
Carried out under anaesthetic, the procedure is best performed before pregnancy or within the second trimester, as it reduces the need to incise scar tissue during labour and limits the risk of third or fourth degree lacerations caused by the foetal head stretching the scarred or closed introitus and perineum.
Defibulation may also be required during a miscarriage, as blood clots and foetal tissue can be retained behind the existing scar tissue and lead to serious infection, including bacterial vaginosis.
The procedure cannot be performed without the consent of the mother, and a caesarean section will not be indicated merely as a result of the presence of FGM. One alternative is to conduct a posterior medio-lateral episiotomy, which is relatively low-risk and allows the mother to retain the FGM.
The advantages of this include the removal of the risk that the mother will be rejected by her husband or family following the reversal of her FGM, and a lower risk of the level of psychological trauma that may have been created by operating along the original FGM scar provoking memories of the initial procedure.
Reinfibulation is currently illegal in the UK, and any healthcare professional found to have carried out or facilitated the procedure can be imprisoned and lose their medical licence.
Awareness and integration
One of the difficulties of treating FGM is the relative lack of awareness and integration between bodies designed to address the issue. In October 2007, FORWARD’s study on the prevalence of FGM in England and Wales highlighted the need for greater collaboration between statutory agencies, third sector organisations and practising communities.
Awareness of FGM has subsequently been raised in recent years. At the 57th session of the Commission on the Status of Women (CSW) at the UN headquarters in New York in March 2013, the UK pledged £35 million to help stop FGM worldwide. And In May 2013, FORWARD held a one-day training course to increase knowledge, awareness and understanding for GPs, nurses, midwives and social workers.
Rachel Johki noted the importance of multidisciplinary action, and said: “There is no justification for FGM: there are no medical benefits whatsoever, compared to male circumcision which can reduce the risk of UTIs, STDs and cancer of the penis.
“FGM is a form of child and domestic abuse, and we must work together sensitively to treat girls and women affected by FGM, and eradicate the practice for good.”
Charlotte Brazier, freelance journalism, Sheffield, UK.
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