Abstract
‘Many studies confirmed that female genital mutilation is mainly performed by health professionals. This in itself acts as a barrier in eliminating the practice.’
Female genital mutilation (FGM), often known as female circumcision, is an endemic practice in different parts of the world, predominantly in eastern parts of Africa. The practice comprises of partial or total removal of external genitalia or other injury to the female genital organs for cultural, religious or other nontherapeutic reasons. The effort for eradication has been relentless for a long time throughout the developing world where the practice is predominant, as well as in developed countries through some governmental and nongovernmental organizations. However, achievements have been minimal in getting rid of this harmful practice, which can possibly be explained by the very complex reasons behind performing FGM. So, in order to reach effective results in the eradication campaigns, it is of paramount importance to understand the reasons behind this practice in every single targeted community. In the 1980s, an extensive campaign around Africa took place, in which presidents of some countries effectively participated. One of the presidents at that time, who is from a tribe that does not perform this practice, condemned FGM in a press conference during that campaign, and the result was that thousands of girls suffered FGM across his country the next day. This reflects the enormous sensitivity about this issue and the vital need to understand the reasons behind the habit and a sensitive, responsible approach for tackling it, especially among healthcare providers.
Reasons behind performing FGM vary according to different communities and cultures. It can be religious, mainly Islam, as some may mistakenly think FGM is mandatory to worship Allah in the right way, although there is no such evidence in Islam to support this practice. An alternative name for the severe form of FGM is the pharaonic type, named after the Pharaoh of Egypt who ordered the circumcision of all women in Egypt in line with the prophecy of a baby boy who will be born and destroy the Pharaohs kingdom. The reason was to make delivery difficult without midwifery help; therefore, allowing him to find out the sex of the born child and have them killed if it was a boy. Prevention of premarital sex and preservation of virginity is one of the strong reasons for performing FGM in some Muslim and non-Muslim countries within the FGM belt, which extends from the Far East to the western coast of Africa. Some African communities undergo FGM because they think it is a sign of transition to real womanhood after the menarche. The myths of achieving good hygiene and better fertility are among the motives for performing FGM. Grandmothers are the main supporters of such practices in some developing countries, which might be a reflection of their illiteracy, as evidence confirmed that level of education is one of the determinants of FGM practice [1].
FGM is a very difficult practice to eradicate, as it has many socio-cultural interconnections. As stated above, the practice has existed since the Pharaohs' time and still continues now, with a prevalence of 90% in some countries. This reflects how deeply rooted it is, in spite of all the medical complications experienced by many victims. These difficulties originate for various reasons. The stigma that is created around uncircumcised girls leads many families to perform it even if not convinced of its necessity. Some girls request it when bullied at school.
‘In order to reach effective results in the eradication campaigns, it is of paramount importance to understand the reasons behind this practice in every single targeted community.’
Connecting the practice with religion (Islam) in some countries is one of the major obstacles in prevention, even though FGM started before Islam. Many religious leaders announce the practice to be against Islam [Abu Sabeeb. Pers. Commun.].
Many studies confirmed that FGM is mainly performed by health professionals [1]. This in itself acts as a barrier in eliminating the practice, as the operation is an income-generating activity for them. While health professionals are expected to be the leaders in eradication, law has an important role, as in many countries where FGM is prevalent law is not enforced, or it does not specifically address FGM [2]. Some countries have medicalized FGM, arguing for harm reduction and having it performed under supervised sterile conditions [3]. This may reduce complications but, on the other hand, will counteract efforts to eliminate the practice, as it will be perceived as safe and legal.
Immigrants from countries where FGM is widely practiced, to countries where FGM is not well known, create a huge burden on the country of immigration, as the need arises for understanding of the practice, the ability to deal with the complications and attempts to stop it being practiced in the country of immigration, or even the country of origin. Many socio-cultural meanings of FGM are difficult to understand. Immigrants might find it difficult to accept people from different backgrounds intervening in their beliefs and cultural issues, which creates a barrier and makes the approach very difficult.
FGM is an infectious practice that can be transmitted from FGM-performing communities to nonperforming ones through intertribal exchange of culture and beliefs. Internal displacement due to war or famine is an alleged cause of this mixture [1].
FGM is considered as a sensitive issue in the areas where it is practiced. Open discussions about the practice do not take place. Men and women do not communicate regarding FGM, and the evidence suggested a lot of misunderstanding. Women claim that they do it to please husbands and uncircumcised girls will not get married, while some men admitted that they prefer to marry uncircumcised woman. Men are experiencing complications themselves [4].
In most countries remote areas usually have higher incidence or more extensive forms of FGM than big cities. Campaigns working against the practice may find it difficult to reach this population. As access is not easy, multimedia facilities are not usually available and there is a higher rate of illiteracy.
FGM eradication needs a multidisciplinary approach. A single measure will not work. First of all there should be a specific enforced law to prohibit FGM and to criminalize the perpetrators. Government commitment to abolish the practice is an essential factor, so as to support governmental and nongovernmental organizations.
‘Immigrants from countries where FGM is widely practiced, to countries where FGM is not well known, create a huge burden on the country of immigration.’
Education through different resources and various approaches to suit each population according to their educational level, access to multimedia facilities and their own motives behind the practice is vital. Therefore, the need for research is paramount so as to identify each population's needs and motives, and the best way to approach this sensitive issue. FGM has to be part of the school curriculum, so that children will grow up with the knowledge of the harmful consequences and unnecessity of the operation. Religious leaders are a key factor in abolishing such a deep-rooted practice. Announcing the practice to be against Islam will have a tremendous effect on the targeted population.
Female empowerment and gender equality is a cornerstone when considering elimination of FGM. Women, being the primary victims, have the right to decide upon their own body. Education and economic independence are important constituents of women's empowerment.
Some countries are already applying some of the above measures, leading to a slow decline in incidence. This reflects how complex and challenging the subject is. Without more extensive, constant and consistent efforts than already exist, FGM will continue to decline very slowly and a significant number of girls in the world will be subject to mutilation. As estimated by WHO, 2 million girls are at risk of FGM each year. In some countries, campaigns for FGM on religious and alleged medical grounds arise [1]; whether these campaigns will counteract the eradication campaigns significantly is unclear.