What is wrong with the people of these African countries?

Do you think that was a broad generalization? Bear with me and you shall see, particularly when you read what this post is about. I am referring to the loathsome, barbaric and absolutely unscientific practice of Female Genital Mutilation (FGM) - often referred to as Female Genital Cutting (FGC) or 'female circumcision' - that is perpetrated in the name of tradition in parts of Africa, Asia and the Middle East, and elsewhere, according to the World Health Organization (WHO) (1). FGM refers to all procedures involving partial or total excision of the external female genitalia or other injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons.

The New York Times reports today (2): The Egyptian government shut down a clinic after the death of a 13-year old girl following clitoridectomy. And that created a huge furore and outcry. Not against the girl's death, no; but against the government! Local supporters of this heinous practice shouted defiance against the government, indicating that they would continue the practice regardless of the official prohibition. Shocking? Read on.

Egypt had made FGM illegal in 1997, but left a legal loophole, which permitted the practice under certain extreme conditions. Finally, it banned FGM a few months back (3) following the death of a 12-year old girl. The Egyptian government is trying actively, forming an unusual alliance amongst government workers, religious leaders and grassroots activists, to stamp out the evil practice. In response to the recent indicent, apart from shutting down the clinic, the Egyptian health minister also issued a decree prohibiting anyone, including healthcare workers, from conducting FGM for any reason. The Ministry of Religious Affairs also issued a booklet calling the practice un-Islamic; Egypt’s grand mufti, Ali Gomaa, declared it haraam (prohibited by Islam); Egypt’s highest religious official, Muhammad Sayyid Tantawi, called it harmful; state TVchannels have been telecasting advertisements discouraging it; and a national hot line was set up to answer the public’s questions about FGM.

But as evidenced in the current incident, radical social change of this kind comes very slowly, particularly to rural Egypt. As such, this country is conservative, religious and, for many, guided largely by traditions; and with the mindset typical in most religious people, blindly following tradition without reason or logic or sense is natural to them, even when those traditions are extremely harmful, and even if those do not adhere to the tenets of their faith, be it Christianity or Islam. For the Egyptian government, therefore, it is an uphill task trying to convince the uneducated, traditional, religious people. As Osama Mohamed el-Moaseri, an influential imam of a mosque in Basyoun (the city near where the 13-year-old girl lived, and died) said, “This practice has been passed down generation after generation, so it is natural that every person circumcises his daughter"... When Ali Gomaa says it is haram, he is criticizing the practice of our fathers and forefathers” (2) - in effect, the same old, tired argument for continued patronage of harmful traditions and ridiculous superstitions by many religious people across the world.

As evidenced in published reports and reviews (1, 4), FGM is practised in 28 African countries, of which 18 countries have prevalence rates of 50 percent or higher, but these estimates vary from country to country and within various ethnic groups. It also is found in the Middle East, particularly in Egypt, Yemen, Oman, Saudi Arabia and Israel, as well as in some Muslim groups in Indonesia, Malaysia, Pakistan and India. Immigrants from these countries have brought FGM to the developed nations, including the United States, Canada, Australia, New Zealand, and parts of Europe, where the incidence is increasing. WHO estimates that at present times, the number of girls and women who have been undergone female genital mutilation is estimated at between 100 and 140 million. It is estimated that each year, a further 2 million girls are at risk of undergoing FGM (1).

Female genital mutilation as practised today include four different types (1):

• Type I - excision of the prepuce, with or without excision of part or all of the clitoris;
• Type II - excision of the clitoris with partial or total excision of the labia minora;
• Type III - excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening leaving a small opening for urine and menstrual blood (infibulation);
• Type IV - pricking, piercing or incising of the clitoris and/or labia; stretching of the clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue; scraping of tissue surrounding the vaginal orifice (angurya cuts) or cutting of the vagina (gishiri cuts); introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of tightening or narrowing it; and any other procedure that falls under the definition given above. The most common type of female genital mutilation is excision of the clitoris and the labia minora, accounting for up to 80% of all cases; the most extreme form is infibulation, which constitutes about 15% of all procedures (1).
  

If you are not already reviled by this barbaric practice, imagine this: It is typically practised on young girls between 4 and 12 years old, mostly by a medically-untrained person - often an older woman from the local culture or community (1, 5), using razor blades, scissors, kitchen knives and even shards of glass, often on more than one girl (5). It may be performed during infancy (even a few days old), childhood, marriage or during a first pregnancy. In recent times, in slightly more 'advanced'(!) localities, FGM is being performed by trained health personnel, including physicians, nurses and midwives (4).

According to WHO, the reasons given by families for having FGM performed include (1):

• psychosexual reasons: Attenuation of sexual desire in the female, maintenance of chastity and virginity before marriage and fidelity during marriage, and to increase male sexual pleasure;
• sociological reasons: identification with the cultural heritage, initiation of girls into womanhood, social integration and the maintenance of social cohesion;
• hygiene and aesthetic reasons: the external female genitalia are considered dirty and unsightly and are to be removed to promote hygiene and provide aesthetic appeal;
• myths: enhancement of fertility and promotion of child survival;
• religious reasons: some muslim communities practise FGM in the belief that it is demanded by the Islamic faith. This assertion is hotly debated amongst muslim scholars (6, 7).

Apart from official bodies such as the WHO, the United Nations and related orgnizations, many health and human rights organizations across the world have strongly condemned the practice of FGM (6-8). According to the World Medical Association statement on FGM (8), regardless of the extent of the circumcision, FGM represents violence and abuse against women of all ages, and severely affects their health and well-being. The immediate and long-term health consequences of FGM may vary according to the type and severity of the procedure performed, but research evidence often shows grave permanent damage to health.

Acute complications of FGM are: hemorrhage, potentially lethal infections, injury and bleeding of adjacent organs and tissues, excruciating pain, urine retention, and ulceration of the genital region (1, 8). Long-term complications include cysts and abscesses, severe scarring, chronic infections, damage to the urethra resulting in urinary incontinence, dyspareunia (painful sexual intercourse) and sexual dysfunction and difficulties with childbirth (1, 8). There is a multiplicity of complications during childbirth including expulsion disturbances, formation of fistulae, ruptures and incontinence. Even with the least drastic version of circumcision, complications and functional consequences can occur, including the loss of all capacity for orgasm (8). Consequences on psychological and sexul health are no less severe; FGM may leave a lasting mark on the life and mind of the woman who has undergone it. In the longer term, women may suffer feelings of incompleteness, anxiety and depression (1, 8).

In order to understand FGM - deeply rooted as it is in the traditions of some societies and cultures - it must be placed within the broader context of discrimination against women, subjugation and compromisation of the dignity of women, under many different cultures mired in tradition, religiosity and superstition. Largely as a result of the work of many international and professional organizations, the detrimental effects of this practice have been documented and are now recognized to constitute a violation of a several universal human rights instruments, including the Universal Declaration of Human Rights (4), that embody an individual's inalienable right to physical and mental health. Today, the world bodies are involved in activities geared towards elimination of the evil of FGM, through advocacy and policy development, research in biomedicine and social science, establishment of training materials and training for healthcare providers (1, 7).

Despite that, as today's NY Times report shows (2), this vile practice continues unabated. Clinicians in the United States are increasingly encountering victims of FGM (9), and there is a growing concern that particularly in the developed countries, following an incident of FGM, it is unlikely that the girl would be brought to a healthcare facility for the treatment of complications because of the fear of legal repercussions (4). More effective strategies are, therefore, needed to deal with FGM, which should involve education and empowerment of women of all ages within their own communities and cultures. The support of right-thinking men, community leaders and other cultures is also vital to stopping the practice, as is the continued presentation of the problem to different governments, so that appropriate programs, laws and policies may be formulated worldwide.

Futher reading:
(1) WHO Factsheet on Female Genital Mutilation - accessed on Sept 19, 2007
(2) The New York Times report, dated Sept 20, 2007
(3) The Guardian report, dated June 20, 2007
(4) FAQ from Womenshealth.gov website of the US Department of Health and Human Services - accessed on Sept 19, 2007
(5) BBC News Health: Medical Notes section - dated 23 December 1998; accessed on Sept 19, 2007
(6) Religioustolerance.org essay on FGM - accessed on Sept 19, 2007
(7) Circumcision Information and Resource Pages (cirp.com) - accessed on Sept 19, 2007
(8) World Medical Association statement on FGM - accessed on Sept 19, 2007
(9) J Midwifery Womens Health. 2007. 52(2):158-63