Female genital mutilation (FGM), also known as female genital cutting and female circumcision, is the ritual cutting or removal of some or all of the external female genitalia. The practice is found in Africa, Asia and the Middle East and within communities from countries in which FGM is common. UNICEF estimated in 2016 that 200 million women are living today in 30 countries-27 African countries, Indonesia, Iraqi Kurdistan and Yemen-have undergone the procedures.
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FGM is typically carried out by a traditional circumciser using a blade; it is conducted from days after birth to puberty and beyond. In half the countries for which national figures are available, most girls are cut before the age of five. Procedures differ according to the country or ethnic group. They include removal of the clitoral hood and clitoral glands; removal of the inner and outer labia and closure of the vulva. In the last procedure, known as infibulations, a small hole is left for the passage of urine and menstrual fluid, the vagina is opened for intercourse and opened further for childbirth.
The practice is rooted in gender inequality, attempts to control women’s sexuality, and ideas about purity, modesty and beauty. It is usually initiated and carried out by women, who see it as a source of honor and fear that failing to have their daughters and granddaughters cut will expose the girls to social exclusion. Adverse health effects depend on the type of procedure; they can include recurrent infections, difficulty urinating and passing menstrual flow, chronic pain, the development of cysts, inability to get pregnant, complications during childbirth and fatal bleeding. There are no known health benefits.
There have been international efforts since the 1970s to persuade practitioners to abandon FGM, and it has been outlawed or restricted in most of the countries in which it occurs, although the laws are poorly enforced. Since 2010 the United Nations has called upon healthcare providers to stop performing all forms of the procedure, including re-infibulations after childbirth and symbolic “nicking” of the clitoral hood. The opposition to the practice is not without its critics, particularly among anthropologists, who have raised difficult questions about cultural relativism and the universality of human rights. The procedures are generally performed by a traditional circumciser (cutter) in the girls’ homes, with or without anesthesia. The cutter is usually an older woman, but in communities where the male barber has assumed the role of health worker he will also perform FGM. When traditional cutters are involved, non-sterile devices are likely to be used, including knives, razors, scissors, glass, sharpened rocks and fingernails. According to a nurse in Uganda who quoted in 2007 in The Lancet, a cutter would use one knife on up to 30 girls at a time. Health professionals are often involved in Egypt, Kenya, Indonesia and Sudan; in Egypt 77 percent of FGM procedures were performed by medical professionals and in Indonesia over 50 percent were performed by medical professionals too as of 2008 and 2016. Women in Egypt reported in 1995 that a local anesthetic had been used on their daughters in 60 percent of cases, a general anesthetic in 13 percent and neither in 25 percent (two percent were missing/don’t know).
Health dangers of FGM
FGM has no health benefits, and it harms girls and women in many ways. The practice involves removing and injuring healthy and normal female genital tissue, interfering with the natural functions of girls’ and women’s bodies. It can lead to immediate health risks, as well as a variety of long-term complications affecting women’s physical, mental and sexual health and well-being throughout the life-course. All forms of FGM are associated with increased health risk in the short- and long-term. FGM is a harmful practice and is unacceptable from a human rights as well as a public health perspective, regardless of who performs it. Some health care providers performs post-FGM treatment to patients, but WHO is opposed to all forms of FGM and strongly urges health care providers to not carry out FGM even when their patient or their patient’s family requests it.
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Short-term health risks of FGM
Severe pain: Cutting the nerve ends and sensitive genital tissue causes extreme pain. The healing period is also painful.
Excessive bleeding (hemorrhage): This can result if the clitoral artery or other blood vessel is cut.
Shock: Shock can be caused by pain, infection and/or hemorrhage.
Genital tissue swelling: This occurs as a result of inflammatory response or local infection.
Infections: May spread after the use of contaminated instruments (e.g. use of same instruments in multiple genital mutilation operations), and during the healing period.
Urination problems: These may include urinary retention and pain passing urine. This may be due to tissue swelling, pain or injury to the urethra.
Impaired wound healing: Can lead to pain, infections and abnormal scarring.
Mental health problems: The pain, shock and the use of physical force during the event, as well as a sense of betrayal when family members condone and/or organize the practice can lead loss of memory or cause one to become insane (this can be temporary or permanent),this is also the reason why many women describe FGM as a traumatic event.
Long-term health risks of FGM (occurring at any time during life)
Pain: Due to tissue damage and scarring that may result in trapped or unprotected nerve endings.
- Chronic genital infections. With consequent chronic pain, and vaginal discharge and itching. Cysts, abscesses and genital ulcers may also appear.
- Chronic reproductive tract infections. May cause chronic back and pelvic pain.
- Urinary tract infections. If not treated, such infections can ascend to the kidneys, potentially resulting in renal failure, septicemia and death. An increased risk of repeated urinary tract infections is well documented in both girls and adult women who have undergone FGM.
Painful urination: This occurs due to obstruction of the urethra and recurrent urinary tract infections.
Vaginal problems: Discharge, itching, bacterial vaginosis and other infections.
Menstrual problems: Obstruction of the vaginal opening may lead to painful menstruation (dysmenorrheal), irregular menses and difficulty in passing menstrual blood, particularly among women with Type III FGM.
Excessive scar tissue (colloids): Excessive scar tissue can form at the site of the cutting.
HIV (Human immunodeficiency virus): Given that the transmission of HIV is facilitated through trauma of the vaginal epithelium which allows the direct introduction of the virus, it is reasonable to presume that the risk of HIV transmission may be increased due to increased risk of bleeding during intercourse, as a result of FGM.
Sexual health problems: FGM damages anatomic structures that are directly involved in female sexual function, and can therefore also have an effect on women’s sexual health and well-being. Removal of, or damage to, highly sensitive genital tissue, especially the clitoris may affect sexual sensitivity and lead to sexual problems, such as decreased sexual desire and pleasure, pain during sex, difficulty during penetration, decreased lubrication during intercourse, and reduced frequency or absence of orgasm (anorgasmia). Scar formation, pain and traumatic memories associated with the procedure can also lead to such problems.
Childbirth complications (obstetric complications): FGM is associated with an increased risk of caesarean section, postpartum hemorrhage, recourse to episiotomy, difficult labor, obstetric tears/lacerations, instrumental delivery, prolonged labor and extended maternal hospital stay. The risks increase with the severity of FGM.
Obstetric fistula: A direct association between FGM and obstetric fistula has not been established. However, given the causal relationship between prolonged and obstructed labor and fistula, and the fact that FGM is also associated with prolonged and obstructed labor, it is reasonable to presume that both conditions could be linked in women living with FGM.
Prenatal risks: Obstetric complications can result in a higher incidence of infant resuscitation at delivery and intrapartum stillbirth and neonatal death.
Mental health problems: Studies have shown that girls and women who have undergone FGM are more likely to experience post-traumatic stress disorder (PTSD), anxiety disorders, depression and somatic (physical) complaints (e.g. aches and pains) with no organic cause.
Even though FGM may be normative and considered to be of cultural significance in some settings, the practice is always a violation of human rights, with the risk of causing problems related to girls’ and women’s mental health and well-being.
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