Royal Society of Medicine Forum: Female genital mutilation – an outmoded practice?

This is a report of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine, held on Thursday 22nd June 2006. . The meeting was chaired by Mr. Eugene Oteng-Ntim, consultant obstetrician and gynaecologist, Guys and St. Thomas' Foundation Trust, London.

The report will be published in the Midwives Journal of the Royal College of Midwives, and appears here with their permission and our thanks.

The meeting was preceded by a screening of the video "Uncut - playing with life", directed by Sandra Obiago, and produced by Communicating for Change, Lagos, with the support of the Ford Foundation and the British High Commission. Chuck Mike, the director of a theatre for development group Peformance Studio Workshop visits Stella Omoregie, who was taught how to circumcise when she was 12years old by her grandmother. Chuck tries to convince Stella to stop circumcising girls, but she refuses to listen to him. She strongly believes this is a good tradition and helps to curb promiscuity. Stella's deep belief in this tradition is shaken when she attends a roundtable discussion in Lagos. During the event, she sees a drama performed by Chuck's theatre troupe in which a woman is circumcised and dies as a result of severe pain and bleeding. Stella sees her life being mirrored on stage and makes up her mind then and there never to circumcise girls again. She joins a campaign to eradicate female genital mutilation in Nigeria, and in 1999 this group succeeds in pushing for Nigeria's first anti-FGM legislation bill to be passed in Edo State.
[The feature film on this subject "Moolaadé" is now generally available on DVD for hire.]

Setting the scene: social, cultural and religious aspects.
Mrs. Comfort Momoh (CM), African Well Woman's Clinic, Guys and St. Thomas' Foundation Trust, London

"I lie on my wedding night groaning, a victim of feminine pain, suffering and sadness. The pregnancy which follows is a glimpse of happiness for me, but the new life endangers mine; the birth promises my destruction. My grandmother named the three feminine sorrows: circumcision, the wedding night, and birth. In the pain of labour I appeal for love lost, the dream broken, and the right to live as a whole human being. And I appeal for the protection of young girls; initiate them to a world not of sorrow, but of love." Another woman described to me the humiliation and agony of her circumcision.

Female genital mutilation (FGM) is a human rights issue for women and girls, denying them bodily integrity and the right to health. 130 million girls and women have been its victims; 2 million are at risk every year. The practice has a centuries-old history, believed to date back to ancient Egypt as a means of controlling fertility. It predates Islam, and has no place in the Koran. FGM is practised in Indonesia and Iraq and about 30 African countries, affecting nearly 100% of women among some communities in Ethiopia, Sudan and Somalia. It varies across cultures, ethnic groups and tribal affiliations; in some countries infants are subjected to it, but the majority of girls are circumcised between 5 and 12 years of age. Some cultures perform female circumcision on adults just prior to marriage or even during the first pregnancy.

The practice has no medical or health benefit; some forms of it are irreversible, and its effects last a lifetime. It is commonly performed by traditional birth attendants, local women or men, or female family members. All are untrained in any formal sense; they usually perform FGM without any anaesthesia, and they frequently damage more of the genital area than they intend.

The specious justifications for the existence and continuation of FGM include tradition and - without any foundation - religion; it is practised by Muslims and Christians alike. The pressures on mothers and women include beautification and hygiene, and the fear of social ostracism and of unfitness for marriage. It is supposed to preserve virginity and prevent immorality by reducing sexual pleasure; a true purpose is to keep women under absolute male control, while for the circumcisers it is the source of their livelihood. If we are to protect children and help women change their attitudes to FGM we must be sensitive to their feelings about it and understand their strongly held beliefs. Consider: FGM is often approached as a ceremony, a festival; imagine the girls' shock when they are subjected to great pain.

10% of circumcised girls and women die shortly after the operation from haemorrhage, shock and infection; sterilisation of the old instruments is far from adequate. The later mortality of a further 25% results from recurrent urinary and pelvic infections and complications of childbirth, such as haemorrhage and obstructed labour, when the risk of dying is doubled. The procedure adds significantly to perinatal mortality. Dyspareunia and infertility are common sequelae, while the emotional impact of FGM is immeasurable.

And all this loss of life and health is perpetuated by poverty, illiteracy, the low status of women and inadequate healthcare facilities.

[The African Well Woman's Clinic at St. Thomas' Hospital, London SE1 provides support, information and advice to women and girls who have undergone FGM, with a one-stop clinic for FGM reversal. We also provide training, conferences and seminars for professionals world-wide.]

The clinical experience. Types and complications of FGM, and the care of the pregnant woman with FGM.
Harry Gordon (HG), Consultant obstetrician, Central Middlesex and Northwick Park Hospitals, London

The first clinic devoted to the needs of circumcised women was started in Northwick Park Hospital in 1993. We are now in a position to document experience and advise on best practice. "This is what we do", I am told by African audiences; in other words "Mind your own business". My other problem is the need to eradicate FGM as practised here. If I am too militant the local religious leaders could empty my clinics.
FGM has its highest incidence in the horn of Africa, and my largest group of clients are immigrants from Somalia. This is the World Health Organisation's (WHO) classification of FGM:

· FGM 1 removes the hood of the clitoris or the whole clitoris.
· FGM 2 removes the clitoris with a variable proportion of the labia, but avoids obstruction of the introitus. Surprisingly this does not prevent orgasm, which nullifies one of the cultural purposes of the operation, that of denying women sexual pleasure.
· FGM 3 (also infibulation or phoronic* circumcision) removes the clitoris and labia, and the raw area is sutured across the midline to leave a small posterior opening for the passage of urine and menses.
· FGM 4 is too often regarded as a therapeutic rather than a cultural issue; it may be used in prolonged labour, but also for other indications including infertility. It includes pricking, cutting and insertion of corrosives into the vagina. The last is becoming popular in Nigeria, and there can be no relief of the resulting stenosis for lack of trained plastic surgeons.

Without death certification the figure of 10% for early mortality following female circumcision is accepted by the WHO, and the stories of my own patients support it. "After the circumcision ceremony there were empty desks at my school".

The WHO hoped to impress African politicians with its multicentre RCT using 28,000 subjects, who might have experienced any of the forms of FGM. The results were horrifying. The FGM group had a perinatal mortality rate (PMR) of 10 to 20 per 1000 above the prevalent baseline 80-90 per 1000, higher rates of haemorrhage and delivery by caesarean section, and longer hospital stays. The politicians are only concerned with the added expense to their health services, and it is to be hoped that these figures will stimulate action.

Most of the women whom I see in London have had FGM 3; the poorer social classes are more likely to have had FGM 1 and 2, and are less likely to emigrate to the West. Also these classifications infrequently result in symptoms requiring the services of a gynaecologist. Many of my patients have a posterior introitus opening less than one centimetre in diameter, preventing penetrative intercourse. Often one also sees a series of small perforations due to poor healing. With day case surgery, adequate anaesthesia and very fine absorbable sutures it is usually possible to restore the anatomy almost to normal; the clitoris is often found to be present, and it can usually be repaired if necessary.

Our inexperienced midwives are alarmed when they see the conditions presented by these women in labour. They need only to be shown how simple it is to open up the area with scissors until the urethra is visible; it is very important that this should be done at the earliest moment to ensure that normal care can be provided thereafter. Blood loss is usually minimal, and delivery with an intact perineum is the norm.

The immediate complications of FGM are as expected: haemorrhage and infection, with a substantial mortality. I have seen little recurrent urinary infection, but one patient developed kidney damage and renal failure following urethral stenosis caused by her FGM. In cases of non-consummation, most common in northern Somalia, a woman's mother is called in to confirm her "virginity", and a circumciser required to open up the vagina. Where the difficulty is partial this is left to the husband's using forceful intercourse. In either case substantial haemorrhage may occur.

It is hard to believe that infertility is a significant effect of FGM, the mean parity in Somalia being six. The Islamic rules of hygiene probably account for a low incidence of vaginal infections. Psychosexual problems might be expected, but are not often a complaint of Somali women, who accept the effects of female circumcision as the normality of a woman's life. However, when faced with the need for pelvic examinations in hospital clinics, some of them suffer from frightening flashbacks to the moment of their mutilation.

When planning to set up a clinic such as mine management needs to be made aware of these physical problems. The name of the clinic is a sensitive matter; any mention of circumcision will be met by opposition from the religious leadership, who believe that involvement in such matters is not the business of Western professionals. Hence "African Well Woman's Clinic". 25% of my patients are self-referred, either because they have no GP or because of difficulties in communicating with their GP. If this sort of clinic is to be successful it will be as a result of word-of-mouth recommendation. The presence of an interpreter is essential, as is a familiarity with the culture and attitudes of the population one is serving. These women do not respond well to referrals within the service, so they are all seen, advised and treated by a consultant for their gynaecological and maternity needs.

The women who come to my clinic are quite specific about their requirement: the relief of FGM and its effects. I have been surprised to learn how many of them are attending other departments for sexually transmitted disease and termination of pregnancy. Neither issue is commonly raised with us, suggesting that ours is a self-selected population which may not be representative of all Somali women. We see two new pregnant patients weekly; we plan for reversals of FGM 3 to be carried out either before pregnancy or at about the 20th week of pregnancy, but only after due discussion with the husband and even other family members. Without this precaution a Somali woman is likely to default from the procedure. They should receive standard obstetric care, but a first caesarean section should if possible be avoided, since the history of CS will not deter them from any number of further pregnancies; a future of multiple deliveries by CS, eventual adherent placenta and severe haemorrhage requiring hysterectomy can then be predicted. Among the gynaecological problems which we see are inclusion dermoid cysts, vaginismus and painful orgasm.

*The word means “relating to the Pharaohs”, although no evidence of circumcision has been found in Egyptian mummies.

Reference.

Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet 2006. 367: 1835-41

The Human Rights Issue.
Ms. Adwoa Kwateng-kluvitse (AKK), Director, FORWARD, London

I am going to address international human rights as they relate to women and girls world-wide, not exclusively to Africans; and it is always girls whose rights are being infringed when FGM is inflicted upon them. The 1948 Universal Declaration of Human Rights guaranteed to all human beings the right to live and enjoy good health and health care, and we know that FGM impacts upon health. The 1979 Convention on the Elimination of All Forms of Discrimination Against Women required all governments to take measures to abolish laws and practices which constitute discrimination against women (and by inference girls). The Convention on the Rights of the Child of 1989 guaranteed freedom from all forms of mental and physical violence and from cruel, inhuman and degrading treatment, and required appropriate measures to be taken to abolish traditional practices which fell within that definition.

In 1995 the Beijing Platform for Action urged the development of policies and programmes to eliminate all discrimination against the girl child, including FGM. The rights of the African child specifically were recognised in a 1979 Declaration and a 1999 African Charter. Last year the important Maputo protocol to this charter stated in its Article 5 that all forms of harmful traditional practices which negatively affect the human rights of women and which are contrary to recognised international standards are to be prohibited. FGM and its medicalisation were specifically mentioned. It must not be overlooked that FGM frequently precedes enforced child marriages with the associated denial of education.

Healthcare professionals who are aware that a child has been or is at risk of being subjected to FGM have no choice but to report the matter as a child protection issue.

Discussion.

A GP described the problems that young Somali women who have been brought to the UK as children already circumcised are having with their sexuality. AKK: At FORWARD we are able to provide one-to-one counselling. HG: These patients should be referred for reversal of their FGM, although this may meet with opposition from their families. There is a danger that they may fall into the wrong hands and receive inappropriate and harmful treatment. A large Sudanese community in London allowed me to speak to them about the history of circumcision in African cultures, and have shown great interest in it; for them it is no longer "something that we do". CM: Young women are attending our clinic for reversal without the knowledge of their parents and with no plans to marry at that time.

HG agreed with a doctor working in Africa that there is a need for epidemiological studies of FGM there. Statistics on adult mortality are unobtainable because there is no certification of deaths, but the study of PNM is possible and meaningful, and research into this has been completed by the WHO. The results have been published in Europe and major African countries, and it is hoped that they will influence African politicians to take action. However progress is inhibited by the indifference of politicians, and by the high regard in which circumcisers are still held in their communities. Some of them have been retrained in family planning in a WHO project which ensured that they received an improvement in their already substantial incomes.

AKK: Although as westernised African women we are likely to be mistrusted in Africa, we must be thankful for the existence of the Inter-African Committee, a NGO active in Africa whose members are local women doing what they can to stamp out harmful traditional practices.

CM: There are encouraging signs of a change in the attitude of African men, some of whom have approached me on behalf of their circumcised wives. AKK: At the request of African women I addressed a group of men, who were receptive. The men say that they are not particularly in favour of circumcision - it is something that the women do. So I suggested that they should at least discuss it with their wives and I asked them to pass my information on to their male friends; this was met with absolute reluctance. Men also say that if they tell women that they have no wish to marry women who are "closed", the women accuse them of lying. I believe that open and honest discussion within the communities could overcome much of their resistance.

AKK: It is important for the bogus link of circumcision with Islam to be removed, and we now have the cooperation of London's Central Mosque with this.

HG: The terms "open", "closed" and circumcised are acceptable to our clients. CM: But it is important to check that they understand what you mean when you use the word circumcised. AKK: Or learn and use their terms, in their languages.

AKK: The FGM Act of 2003 introduced the concept of extraterritoriality, making it an offence for parents to remove any girl with British nationality or permanent UK residence to anywhere in the world in order to undergo FGM. These girls will tell you that they are to be "taken home for a holiday". HG: Both Adwoa and I have been involved in successful court cases where a girl's passport has been removed and she has been placed in the care of the social services. It is however vital that a girl in these circumstances should not be removed from her family; the principles to be applied must be the same as for any other form of child abuse. CM: The aim is to talk to the family, support them and attempt to modify their attitudes.

Asked by a gynaecological SPR what was the scale of the risk of being circumcised for girls in this country HG replied that the number is very low if any. A substantial number of cases would have resulted in serious complications or deaths, and girls would have been referred to me by paediatricians. The families are aware of the law now, and will try to take their children out of the country for a circumcision; the European centre of this trade at present is Amsterdam.

Asked how gynaecologists could best act to protect children, HG replied that they must proceed with great discretion; let it be known that you are setting up an advice and reversal service, and provide the best possible service that you can. If you are seen to be an activist you will lose your clients.

In responding to a question from the chair, CM recommended that the way to get the support of a hospital trust or PCT for the establishment of a FGM clinic is to demonstrate to them that there are sufficient numbers in the community in need of the service.

CM: There is still a widespread lack of awareness of FGM among the healthcare professions, who rarely make the connection when faced with suggestive presenting symptoms. "I will be away for a while, and when I come back I'll be a woman (or I will be sore down below)". Immigrants and asylum-seekers are now dispersed throughout the country. HG: An example: Because the maternity unit remained unaware of a woman's FGM 3 throughout her prolonged labour she was never catheterised as was necessary, and suffered subsequently as a result. AKK: FGM needs to be in the core training curriculum for all these professionals, including social workers and teachers. Fortunately the Department of Health is shortly to circulate information on this subject throughout the professions. A consultant gynaecologist revealed that the Royal College is soon to publish a Green Top guideline on the subject of FGM and its management. This will reach all UK obstetricians and gynaecologists and it should inform their training of staff and students. There is also an Antenatal NICE guideline on the subject which is shortly to be updated .
A student of the University of Huddersfield told us that theirs is the first year in which a module on FGM has been included in the course.

HG: The Health Authority is closing my clinic at the Central Middlesex Hospital next week to save money. AKK: Deplorable! CM: We are petitioning against this.

CM: The St. Thomas's clinic sees self-referred women from all over the UK and even from abroad. I average two to three reversals weekly, carried out under local anaesthesia. I pass on my own knowledge of clinic administration and my skills to others whenever possible, but with due consideration for the sensitivities of women who are averse to having strangers in a consultation. AKK: There are now 13 such clinics in the UK, the most recent to have opened being in Acton.

HG: No objection is raised when FGM has to be reversed urgently during labour, since this is what would be done in the home country. A problem for Sudanese women is that they will wish to be re-sutured after delivery, and it has to be explained to them that this is illegal here. It is interesting that although FGM has been illegal in the Sudan for 50 years it is nonetheless universal, and all the women are re-sutured after a birth. AKK: When this is discussed during pregnancy it is important to mention the legal issues, to include the child-protection aspect, and to explain the anatomical change of which the woman will later be aware, using diagrams. The longer the talk time, the better the chance of changing attitudes. Health visitors should be put in the picture, particularly if the baby is a girl.

The chair: You are clearly winning the political argument, and have gained the confidence of your clients, but how does a NGO like FORWARD get its funding? AKK: The Department of Health provides core funding which pays our rent and covers the salary of the administration and of the finance officer; the Lottery Fund and other charities provide the rest of our income, but funding remains a problem. CM: As long as proper applications are made the NHS pays for surgical procedures in our clinic through the department of gynaecology.

CM: When you return to your places of work please convey as much as possible of the information you have received here to your colleagues. Awareness is the key. 1