Figure 1: Prevalence of FGM
What is FGM?
FGM is a form of child abuse and is illegal in the UK; the Serious Crime Act 2015 extends this illegality beyond the UK, prohibiting acts of FGM committed abroad by a UK national or someone who is resident in the UK. Female Genital Mutilation (FGM) is described by the World Health Organisation
‘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’.
This procedure has no health benefits for women and girls, can cause severe short and long term health problems and is recognised internationally as being a violation of the human rights of women and girls.
FGM is sometimes referred to as ‘female genital cutting’ or female circumcision’. However, it is preferred not to associate FGM with circumcision due to the severity of the procedure in comparison to male circumcision. Male circumcision involves removing the foreskin of the penis without causing damage to the penis, whereas FGM can cause significant health problems for the women and girls involved.
Whilst FGM is the preferred term, in communities where FGM takes place there are often local terms for this. Forward
have identified various terms that may be used in communities in order that practitioners can discuss the procedure with survivors.
There are four types of FGM:
Type 1: Clitoridectomy- This is partial or total removal of the clitoris and or the clitoral hood.
Type 2: Excision- This is removal of the clitoris and the labia minora, sometimes this will also include removal of the labia majora.
Type 3: Infibulation- This is the tightening of the vaginal opening through creation of a ‘seal’.
Type 4: Other- This includes any other form of procedure on the female genitalia for non-health reasons, such as piercing, pricking, incising, scraping and cauterizing the female genitalia.
FGM is most often performed by someone with no medical training, often elders who play a central role in the community, and conducted in unsterile or unsanitary conditions. Girls are given no anesthetic, no antiseptic treatment and are often forcibly restrained. The cutting is made using instruments such as a knife, pair of scissors, scalpel, glass or razor blade, sometimes the same blade is used to cut several girls. In some countries FGM is performed by health professionals in a ‘medicalized’ setting, such as Egypt, Guinea, Kenya, Nigeria, Northern Sudan, Mali and Yemen (Serour, 2013). This is still harmful with many short and long term health impacts.
FGM is a worldwide issue with an estimated 200 million women living with FGM in the world (World Health Organisation (2), 2016). However, women and girls from some communities are at increased risk. In some African countries, such as Somalia, the estimated prevalence of FGM is as high as 98%.
A more detailed map showing prevalence of FGM (Unicef (2), 2016)is shown in figure 1
Figure 1: Prevalence of FGM
Source: UNICEF global databases, 2016, based on DHS, MICS and other nationally representative surveys, 2004-2015.
The highest FGM prevalence rates, 90% or more, are found in Djibouti, Guinea, Sierra Leone, Somalia and Sudan. Eritrea, Egypt and Mali also have very high prevalence rates, more than 80%.
The type of FGM performed is often linked to ethnicity. For example, one in five daughters has undergone the most invasive form of FGM, type 3, in Somalia, Eritrea, Niger, Djibouti and Senegal (Unicef (1), 2016).
In Britain, FGM is seen in ethnic groups that have migrated from Egypt, Eritrea, Ethiopia, Gambia, Iraq, Kenya, Kurdistan, Liberia, Mali, Nigeria, Northern Sudan, Sierra Leone and Somalia. Dispersal of asylum seekers across the UK makes increasing numbers of all education professionals likely to come into contact with girls and women who have undergone and girls who might be at greater risk (Nottingham City and Nottinghamshire County Safeguarding Boards, 2016).
It must be acknowledged that dual heritage girls may also be at risk of FGM, particularly if FGM has been carried out on their mothers, sisters or extended family (NSPCC, 2016).
Risk factors for FGM
FGM is mostly carried out on girls sometime between infancy and adolescence, however, FGM can happen at any age. In the UK young girls at risk of FGM between the ages of 7 and 10 years of age, although it is acknowledged FGM can happen at any age (Nottingham City and Nottinghamshire County Safeguarding Boards, 2016). Risk factors for FGM include:
A history of FGM in the family; especially if the mother has undergone FGM
Being a woman/girl are from a community or ethnic group where FGM is highly prevalent and a part of the culture of that community (although this does not always mean FGM will take place).
Local intelligence suggests girls are also at higher risk of FGM in the run up to and during the school summer holidays, as they are able to have a longer time off to recover from FGM before returning to school.
FGM is sometimes considered as having a religious connection. This is not the case and in no holy book is FGM endorsed. Some people who are Christian, Muslim and Jewish carry out FGM, some people of these religions do not, it is not specific to a religious faith and not all people of that faith will conduct this practice.
Worldwide economic pressures can play a part in perpetuating the practice of FGM. Some practising communities believe their daughter will not marry unless she has undergone FGM. This belief alongside the reliance on dowry for family income perpetuates the practice of FGM, particularly in rural communities. In most countries, FGM prevalence is lower among girls in the wealthiest households (Unicef (1), 2016).
In addition, community elders often play the role of cutter for the whole community, earning a living conducting FGM for a fee, so it is in their interest to perpetuate this practice. There are various ‘given reasons’ for practicing FGM, for example women and girls are told they will gain respect and honour for themselves and their families. These ‘given reasons’ pressure women and girls to undergo FGM. ‘Given reasons’ for FGM include:
The procedure will increase marriageability of the woman/girl
To protect a girl’s virginity, ensure premarital virginity and marital fidelity
Perceived cleanliness: girls are told that female genitalia is dirty and this procedure will make the them more hygienic (World Health Organisation (1), 2016)
To maintain the family’s honour
The community will disown the woman/girl if she does not have the procedure
It is tradition and ‘a rite of passage’, or part of ‘coming of age’ (Guardian, 2011)
If the clitoris is not cut it will harm the woman’s husband/ keep growing/ harm the baby during delivery. (Forward, 2014)
Whatever the reasons advised for the practice, FGM is child abuse, it is illegal and it violates human rights, that women and children should be protected from cruelty and violence.Health implications.
FGM has no health benefits and is harmful to girls and women. It involves removing and damaging healthy and normal female genital tissue and interferes with the natural functions of girls' and women's bodies. Generally speaking, risks increase proportionately with the severity of the procedure.
There are health implications for all women and girls who undergo FGM. Health impacts caused by FGM can include (but not exhaustively), in the short term:
excessive bleeding (haemorrhage)
genital tissue swelling
fever due to wound infection
urinary problems (difficulty and pain passing urine)
injury to the surrounding genital tissue
Health impacts in the longer term can include:
psychological problems including post-traumatic stress disorder, anxiety and mood disorders and low self-esteem
problems with childbirth which can put both mother and baby at risk including difficult deliveries, the need to resuscitate baby and haemorrhage
difficulty passing urine and urinary tract infections
difficulties in controlling menstruation
increased risk of infection
pain and/or difficulty having sex and reduced sexual satisfaction
vaginal problems including discharge, itching, bacterial vaginosis and other infections), keloid scar tissue and keloid
renal problems and renal failure.
Dependent on the type of FGM performed there can also be the need for later surgeries such as de-infibulation, which may be required to enable sex or childbirth. De-infibulation is the surgical procedure of opening the closed vagina following type 3 FGM. In some affected communities de-infibulation can be followed by re-infibulation and this cycle may be carried out multiple times, for example on the wedding night or prior to childbirth.
The resulting serious physical, psychological and social effects are devastating to all women involved. Many of these women do not access services or treatment until it becomes absolutely necessary; normally during pregnancy or where there has been recurrent pain, infections, etc (McNiven, 2015).