Introduction
Although the origin of FGM is uncertain, there is evidence from Egyptian mummies that female circumcision was routine practice 5000 years ago (Elchalal et al., 1997). In ancient Rome, slaves had metal rings passed through the labia minora to prevent procreation, and women in medieval England wore chastity belts. These practices are not specifically associated with any particular religious faith, as they have been observed in Muslims, Jews, Christians, and animists alike (Morris, 1999), and actually predate these religions.
Although FGM is commonly perceived in present-day Western countries to be a ‘foreign’ phenomenon, clitoridectomy (the surgical removal of the clitoris) was a recognized practice in 19th century Britain in the management of epilepsy, sterility, and masturbation (Kandela, 1999). Some of the ‘clinical’ justification demonstrated attitudes towards women similar to those in many other parts of the world today. In the twentieth and twenty-first centuries, there has been an international drive by organizations such as the WHO and Amnesty International emphasizing the human rights violation of girls and women through this procedure. Various national governments have also set up legislative frameworks to abolish and criminalize FGM.
Discussion and Analysis
Many explanations have been put forward to explain the practice of FGM, varying with individual culture. These include maintaining marital fidelity, controlling the female sex drive, preventing lesbianism, ensuring paternity, calming the female personality, and preventing the clitoris from growing long like the penis (Eke &Nkanginieme, 1999). Other reasons cited are to improve hygiene, aesthetics, and community belonging and to enhance fertility—these explanations are arguably partly driven by ‘sexist’ views of women as subservient to men and second-class citizens of society.
Traditional FGM is often carried out on girls between the ages of two and 12 (Barstow, 1999). However, in some cultures, it is carried out in adolescence, just before marriage, or at childbirth. The ‘operator’ is usually an older woman in the community, either a relative or a traditional birth attendant.
In some situations, FGM is carried out without anesthesia, antiseptics, analgesics, or antibiotics (Barstow, 1999). Surgical instruments may not be available, and the ‘surgery’ is carried out using whatever is available, for example, sharp rocks, razor blades, broken glass, or even the operator’s teeth (Barstow, 1999). FGM by qualified medical personnel may be carried out in sterile surgical conditions with local or general anesthesia. In fact, a survey of the views of a group of male Egyptian medical students found 22% had no objections to carrying out female circumcisions as doctors (Refaat et al., 2001).
In traditional societies where FGM is practiced a woman may be perceived to be unworthy of marriage if she has not undergone circumcision (Omer-Hashi et al., 1995). This is because circumcision is thought to guarantee female chastity. It is interesting that no such constraints are put on men, but men have traditionally preferred chaste women in order to ensure their paternity (Bhugra, 1998). Lax (2000) says that psychoanalytical findings indicate that the motive for FGM is based on men’s unconscious fear of women’s sexuality and the need to suppress it.
This suggestion is understandable in that, while FGM suppresses female sexuality by diminishing the capacity to enjoy a sex life, increased pleasure from tightening of the vagina has been described by some males. In many societies, women assume the role of the submissive wife, child-bearer, and mother. However, in recent years this stereotype has been challenged in many societies the world over, as women have become increasingly socially independent of men. Mackie (1996) compares FGM to foot binding in China and asserts that both practices originated in an attempt to ensure exclusive sexual access for the male.
He suggests that FGM may be eradicated in a similar way to foot binding by forming associations of parents who pledge not to let their daughters undergo FGM, or let their sons marry women who have undergone FGM. This may be complicated by the fact that a significant proportion of FGM is perpetrated by women, some of whom are willing to assume a submissive role. Joseph (1996) suggests that FGM is perpetuated by the ‘split-off internal and cultural sadist, women who have dissociated from their own relationship to pain and project it onto the bodies of their children. This simplistic view suggests that women who have undergone FGM feel that their own children should undergo what they endured (Williams & Sobieszczyk, 1997), hence perpetuating cycles of pain.
However, this ignores the importance of circumcision in the cultural rites of passage from childhood to adulthood, in which the status of women is raised significantly. It is therefore clear that if FGM is to be eradicated there must be fundamental changes in both the attitudes of men and women and in attitudes about women and female sexuality across cultures. The independence and individual sexuality of women should be attributes that are celebrated and not suppressed.
FGM is also associated with various degrees of psychological morbidity. Lax (2000) described psychological consequences following FGM such as “loss of trust, prevailing lack of bodily well-being, post-traumatic shock and depression”. Interestingly, the psychological morbidity following the procedure in countries where FGM is culturally acceptable or prevalent is thought to be minimal (Black & Debelle, 1995). In fact, these authors argue that not being circumcised in certain communities has a greater psychological impact than the trauma caused by circumcision itself. This is because, as discussed above, not being circumcised in certain communities is to become a social pariah.
Black and Debelle (1995) suggest this is less likely to be a problem among those living societies where FGM is routine, as experiences are normalized. Studies of PTSD in refugee children fleeing persecution and conflict demonstrate that the prevalence of PTSD is proportional to the level of traumatic exposure (Almqvist & Brandell-Forsberg, 1997). One can postulate that the prevalence of PTSD is likely to be higher in girls who undergo the more extensive procedures, or whose procedure was associated with serious complications. PTSD is associated with flashbacks triggered by reminders of the traumatic event and may be accentuated by experiences such as sexual intercourse, gynecological examination, and childbirth in vulnerable persons.
As a consequence of FGM, many women are affected by chronic pain syndrome and mobility impairment (Lightfoot-Klein, 1993). The chronic pain may be linked directly to the trauma of the procedure, or be a result of the complications that ensue, such as infection or menstrual difficulties. As with other causes of chronic pain, there is an increased risk of depressed mood, with reduced social functioning, worthlessness, guilt, and even suicidal ideation. Limited mobility also increases social isolation and role loss in society. Sadly some women fail to present to medical services because to do so they must first seek permission from their husbands or other male members of their family (Lightfoot-Klein, 1993). In addition, the husband may insist on being present during consultations, potentially restricting the discussion of emotional difficulties.
In some societies, the failure to produce children is blamed on women, and may even be attributed to a curse. This can result in the woman being rejected by her husband and even by her extended family, resulting in further social isolation. While there has been much focus on the sexual and psychological problems that FGM causes for women, the emotional and physical needs of their partners and the impact on their relationship are often neglected. Emotional or physical pain during intercourse diminishes the enjoyment of both the woman and her partner and the woman is reduced to a masturbatory object during sex (Longmans et al., 1998). This certainly has implications for intimacy in the relationship.
In some countries, specialist centers have been developing that offer a surgical reconstruction of the female genitalia (Momoh et al., 2001). These procedures potentially reverse or reduce the risk of physical and obstetric complications, and consequently may reduce psychological difficulties. Great sensitivity is needed when providing this sort of care, however. As many myths surround FGM, these must be explored in a culturally sensitive manner. In addition, the gynecologist carrying out the procedure must be aware that routine examination and instrumentation of the vagina may trigger flashbacks, and that the idea of a further surgical procedure, albeit repair, maybe a source of distress as well.
While it is essential to approach FGM in a culturally sensitive way, there is a danger that some health professionals might avoid interventions for fear of being perceived as racist. Eke and Nkanginieme (1999) argue that shying away from the issue for the sake of political correctness is morally unacceptable, as the fear of being culturally out of one’s depth may cause neglect of the medical and psychological needs of circumcised women. FGM is an ancient cultural practice that still affects many women around the world today. While the original aim was to ensure women adopted a submissive position towards men in society, societal shifts, human rights awareness, and changes in sexual roles make it unnecessary in modern society. (Dandash, 2001)
Conclusion
Its continued perpetuation is dependent on the interplay of culture, lack of awareness, and acceptance in some societies. With an increasingly ‘multicultural’ society and an increasing migrant population, it is likely that healthcare professionals, especially those in inner-city areas, will come across women who have undergone FGM. Because of the nature of the procedure, this contact is most likely to occur in primary care, pediatrics, obstetrics and gynecology, and psychological or psychosexual services. Increased awareness of the practice is essential among all health and social science professionals, as well as an integral part of training curricula.
While the healthcare professional is likely to find the practice of FGM abhorrent, it is essential that the topic be approached with cultural sensitivity as without this there is unlikely to be trusted, and thus little chance of a successful outcome to the clinical encounter
A lack of awareness of how differently and subtly psychiatric problems may manifest in different cultural groups may influence referral pathways, as some women are unlikely to present to health services. There may also be traditional support resources within their own community. The role of close liaison between primary care, pediatric, obstetric and gynecological, and psychological services on the one hand, and these immigrant communities on the other, can not be over-emphasized in changing attitudes and health education about the practice of FGM.
The challenge of changing these attitudes also needs sustained campaigning by international, non-governmental, human rights, and national organizations on the deleterious effects of female circumcision. However, in the meantime, we have a duty of care to girls and women who have undergone such procedures, as well as to prevent further perpetuation of their daughters. This can only be achieved if healthcare professionals demonstrate adequate awareness of the origins, traditions, and psychosocial implications of genital mutilation with cultural sensitivity.
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