HEALTH EFFECTS OF FEMALE GENITAL MUTILATION IN ETHIOPE EAST LOCAL GOVERNMENT DELTA STATE
CHAPTER ONE
Objectives of the research
General objective
The main objective of the study was to assess FGM practice and its effects on women’s health in Delta State, Nigeria.
Specific Objectives
- To determine the socio-demographic characteristics that influence FGM practice in Delta State, Nigeria
- To establish women’s knowledge and attitudes on FGM risks and eradication programs in Delta State,
- To determine the effects of socio cultural and religious beliefs on FGM eradication programs in Delta State,
- To determine the reproductive health complications associated with FGM and how they are managed in Delta State.
CHAPTER TWO
LITERATURE REVIEW
2.1 Introduction
This chapter presents a review of related literature on various aspects of FGM. It lays out a description of the types of FGM practiced globally and in the study area, Nigeria. It also reviews women’s knowledge and attitudes towards FGM as well as other socio-cultural and religious determinants of FGM. Health complications experienced during and after FGM are also highlighted herein.
2.1.1 Types of FGM
The World Health Organization (WHO) classifies FGM into four types depending on the extent of tissue removed (Berg & Underland, 2013). 1.) Type 1(Sunna Type), the mildest of the types, involves partial or total removal of the clitoris and or the prepuce, 2.) Type II (Sunna Kabir) involves partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. 3.) Type III, (infibulation), is the most extensive involves narrowing of the vaginal orifice with creation of a covering seal by cutting and a positioning the labia minora and or the labia majora, with or without excision of the clitoris (Yasin et al., 2013). WHO (1996) also suggests a fourth form Type 4, which includes unclassified procedures such as cauterization of the clitoris, cutting of the vagina and the introduction of corrosive substances or herbs into the vagina for the purpose of tightening or narrowing it (Pereda, Arch, & Perez-Gonzalez, 2012)
2.1.2 Reasons for the practice of FGM
Traditionally, the arguments that support FGM have been based on cultural, religious and social beliefs within families and communities, although religion actually offers little support and justification for the practice. The reason why the practice of FGM is performed and perpetuated has more to do with social convention, tradition and cultural ideals of communities ( Pereda, Arch, & Perez-Gonzalez, 2012).
Research has shown that in cultures which defend the practice, majority of the most highly educated classes such as university students, continue to believe that it is a religious dictate (77.4% of males and 50% of females), this being especially the case among Muslim students ( Pereda, Arch, & Perez-Gonzalez, 2012). Communities have several reasons as to why they practice FGM. FGM is often described as a means to safeguard against premarital sexual activity and as such prevent promiscuity and preserve virginity. In Kenya, 30% of women supporting continuation of the practice agreed that FGM helped to preserve virginity and avoid immorality, in Nigeria, similar rates of 36% were reported by women, while 45% of men supporting continuation of the practice agreed with this statement (Yirga et al., 2012).
FGM was believed to be proof of a girl’s virginity, thereby improving the marriage prospects of unmarried girls who have undergone the procedure. In Côte d’Ivoire, “improved marriage prospects” was cited by 36% of women favoring continuation of the practice once married. FGM is also believed by some communities to ensure that a woman is faithful and loyal to her husband (Yirga et al., 2012). There are a number of reasons why this practice continues today, including chastity, religion, culture, aesthetics and hygiene and socio-economic factors. Almost all of these are linked to girl’s social status and marriage ability. This all comes down to power over women (Molleman & Franse, 2009).
2.2 FGM in Nigeria
The Inter-African Committee on Traditional Practices affecting the health of women and children and WHO have adopted the term FGM because not only is it used as an effective policy and advocacy tool but is also a more apt description of the physical act and extent of injury on the genitalia when the procedure is performed (Berg & Denison, 2013). Although current trends indicate that the practice is becoming less prevalent, as many as 30 million girls under the age of 15 may still be at risk of FGM. In countries where more than 70% of women aged 15-49 years live with FGM for example Eritrea, Ethiopia, Mali and Nigeria, fewer daughters than mothers have been subjected to FGM. Women who underwent FGM are also noted to support continuation of FGM. An example is in Ethiopia where 31% of women believe that the practice should continue (Berg & Denison, 2013). The entire Africa FGM prevalence is illustrated in annex VI, table 1.1. WHO notes that most girls undergo this practice between birth and age 15, but FGM occurs at all ages (Human Rights Watch, 2010). FGM is performed on girls at different ages, but most commonly around the ages of 7 – 10 (The National Education Toolkit for FGM in Australia (NETFA, 2014). Sometimes it is performed on babies and sometimes on women when they are much older. Some sources say that in Nigeria, FGM is carried out on girls between 3 and 8 years of age while other sources set the age range between 4-12 years (Matsuuke, 2011). In some cultures, FGM is used to initiate girls into adulthood and to ensure their marriage ability (Human Rights Watch, 2010; NETFA, 2014).
Normally FGM is carried out by a traditional practitioner and mostly the operations are carried in the villages and not in a health institution (Matsuuke, 2011). In a study done by the World Bank in 2004 it was noted that in most parts of Nigeria, traditional circumcisers (Guddaay) conduct most operations. The number of professional health providers who carry out milder forms of circumcision to girls for a fee was also found to be increasing but at the same time these professional health providers were found to be also discouraging the work of traditional circumcisers and the Pharaonic FGM. Complications arising from FGM were found to be turning more families towards health providers, trained TBAs and nurses who perform whatever type of FGM parents’ desire (World Bank, 2004).
2.3 Socio demographic characteristics that influence FGM
In a study by Karmaker et al. (2011) which involved 12,049 women, results showed that age and religion were the most significant demographic variables associated with the risk of FGM in Burkina Faso. As age increased, the proportion of women and their daughters who had undergone FGM increased.
Success of these community-led interventions varies between communities. A long- term evaluation of an intervention in Senegal showed a reduction of prevalence in the youngest generation (0-9 years of age) of almost 70% and in another area in the same country, the reduction was about 24%. However when run in neighboring Burkina Faso only 3% reduction was identified compared to the control group. When the same programme was run in Nigeria, the public declaration achieved was only to change the type of cutting from the pharaonic cut to the sunna cut rather than the abandonment of FGM. These variations are suggestive of the differences in social and religious factors in this communities (Johansen, et al., 2013).
In a study by Yirga et al. (2012) which was conducted among 858 females of reproductive age (15-49 years) in the year 2008, it was concluded that the likelihood of girls and women undergoing FGM might be related to socioeconomic factors. The results showed that 80% of the women were illiterate and unemployed. The researchers also concluded that the practice of FGM was therefore, considered to be a societal norm and a source of income for the perpetrators. Girls terminate their education to meet their family responsibilities at an earlier age and the options would be marriage or becoming engaged. In Ethiopia, there is a tendency for families with no or little education to keep their sons and daughters at home to serve the family and help with agricultural work. Therefore poverty, lack of education, insufficient information and inadequate knowledge might put this women at a risk of becoming victims of FGM (Yirga et al., 2012).
The health consequences for women are very serious and can include recurrent urinary tract infections, severe pain during sexual intercourse, infertility, difficulties in bearing children and increased risk of neonatal death (Molleman and Franse, 2009). Women who have undergone any form of FGM are traumatized and likely to develop physical, psychological and social problems. The physical and psychological trauma results in poor quality of life and low self-esteem during adulthood. Psychological problems can also be seen in women in the form of diagnoses like anxiety, phobia and low self-esteem (Peltzer & Pengpid, 2014). Women with type 2 and type 3 FGM are more likely to require cesarean section and have postpartum hemorrhage than women who had not had FGM (Yirga et al., 2012). Scar tissue that develops after the practice of FGM leads to problems during child delivery like obstruction, tears and or need for an episiotomy.
FGM also contributes to high health care demands and medical costs. Spontaneous deliveries do not need as many healthcare resources as cesarean sections or other assisted deliveries. The procedure is also done mostly in unhygienic conditions hence it can be predicted that contagious and blood borne diseases including Human Immunodeficiency virus due to use of the same instruments in multiple operations can be spread from one person to another. New born from mothers who have undergone FGM might have a complication during birth and birth injury; this may be costly to treat afterwards. A WHO study in six African countries revealed that the annual cost of FGM related obstetric complications amounted to $3.7 million and even more so when performed on young girls who are put through enormous suffering. The annual cost ranged from 0.1%-1 of government spending on health care for women aged 15- 45 years (Yirga et al., 2012). Social systems are key to families not being isolated. Therefore some families are forced to practice FGM due to fear of discrimination for deviating from community norms (Yirga et al., 2012).
2.4 Women’s knowledge and attitudes towards FGM
When people lack awareness of how their behavior affects their health and wellbeing, they have little reason to put themselves through the misery of changing the risk behaviors they have engaged in for many years. Although increased knowledge creates a precondition for change, additional communal or self-influences are needed to overcome the impediments to adapting and maintaining new behaviors. As much as there are many behavior change theories, changing the behavior of FGM requires a unique approach as the Female Cut (FC) is a communal rather than an individual behavior ( Gele, Bo, & Sundby, 2013b).
In a study by Yasin et al. (2013) conducted in Erbil city, involving 1,987 women aged 15-49years, it was generally agreed that the women’s education may have contributed to a reduction of the practice of FGM. This was a contradiction to several studies that have reported a negative association between FGM and the education level of mothers. The findings of these other studies suggested that education alone is not sufficient to lead to the abandonment of FGM and may show the superiority of traditions, cultural beliefs and religious dictate over education. In the study by Yasin et al. (2013), the results also showed a significant association between FGM and the education status of the father. This may have reflected the decision making process on FGM in the family and the society and the potential power of the father which agreed with a study in Egypt. Research from other settings like Gambia has shown that the decision making for undergoing FGM is in a large part made by mothers. However there are instances where it is a joint decision by both mother and father with the latter only informed to obtain his agreement (Yasin et al., 2013).
In a study by Karmaker et al. (2011) which involved 12,049 women, the results showed that there was higher prevalence among women with no education and their daughters. The study also found that education was associated with a reduced likelihood of undergoing FGM for both Protestant and Catholic women but not for Muslim women(Karmaker et al., 2011). In a study conducted in Kenya by Livermore, Monteiro, & Rymer (2007) showed that awareness of complications of FGM is greater than awareness of both the law against FGM and educational programs.
2.5 Effects of socio cultural and religious beliefs on FGM
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Socio cultural aspects of FGM
Globally as the campaign against FGM continues to gather momentum, researchers have focused mainly on the socio cultural, legal and clinical aspects of FGM. There has also been an increasing awareness among clinicians and human rights campaigners that understanding the motives behind the socio cultural elements may be an avenue towards abandonment of the practice (Ezenyeaku et al., 2011). FGM is a very delicate topic that is deeply entrenched in the tradition and culture of many communities in Africa and in many religions FGM is regarded as interference in tradition and a dictation from the communities in the western world. Religion, particularly Islam, is used very often as an argument for FGM, although some scholars have found out that in the Holy Qur’an and in Islam there is no single justification for FGM (Molleman & Franse, 2009).
FGM is a practice which is multifaceted and deeply rooted in a strong cultural and social framework. It is endorsed by the community and supported by the loving parents with what is believed to be the best interests of a young girl at heart. FGM can only be understood within its cultural context, for in the societies where it is practiced, despite its harmful physical effects, FGM provides women with many social and cultural benefits. As much as beliefs about FGM vary from one ethnic community to another, there are several themes that are common (FGM New Zealand, 2016). These common themes in beliefs are as follows: Many societies believe that FGM prevents the women and girls from being promiscuous. This they believe is to tame the girl so that she is not oversexed. FGM is held high in societies where virginity is a prerequisite for marriage. In these societies any form of extramarital relationship is punishable by extreme penalties. FGM is therefore believed to preserve their virginity, prevent them from being oversexed, and save them from temptation and disgrace. In times of war FGM is also thought to protect women from rape. In other societies FGM is associated with family honor, which is of vital importance in the Horn of Africa. The most dishonorable experience for a man is the sexual impropriety of a female member of the family, and once lost it cannot be restored. In some communities they also believe that FGM promotes fertility and increases the man’s sexual pleasure, both of which enhance a woman’s attractiveness in marriage.
Many groups that practice FGM come from patriarchal societies whereby resources and power are passed down and held solely under male control, with a woman’s access to land and to economic resources being exclusively through her husband (or the male members of her family). In order for a woman to be eligible for marriage it is essential that she is a virgin, the association between virginity and FGM is so strong that a girl who has not undergone infibulated or excision has virtually no chance of marriage, regardless of her virginity and worse of all has no access to land and future resources (FGM New Zealand, 2016). Other societies practicing FGM are patrilineal, whereby a woman represents and retains her father’s lineage and her marriage is not only a union of two people, but an alliance of two lineages. This alliance strengthens clans and clan relationships with other groups and a woman who has not undergone FGM brings great shame and dishonor to her father’s lineage.
Most women who are affected by FGM come from rural areas and have limited access to reproductive health education. Many myths especially those on hygiene have been passed from generation to generation. In areas where there is high infant mortality and fertility is important, FGM is promoted as a prerequisite for the cleanliness of a woman and the good health of her baby. In Nigeria, the external female genitalia are considered as dirty, ugly and disfiguring. Infibulation is believed to produce a clean smooth skin surface that is desirable to touch (FGM New Zealand, 2016).
FGM is considered to play a significant role in men’s sexuality in the Horn of Africa. The narrowed vaginal opening is believed to enhance a husband’s sexual pleasure and the challenge of penetrating a tight opening is considered to be linked to a man’s virility. In societies where polygamy is the norm, it is thought to be physically impossible for men to satisfy the many wives they have hence the practice of FGM comes in handy as it makes the wives less sexually demanding (FGM New Zealand, 2016).
CHAPTER FIVE
DISCUSSION, CONCLUSION AND RECOMMENDATION
5.1 Discussion
Heath complications associated with FGM
Majority of the women perceived that FGM was associated with health complications including pain during sexual intercourse; bleeding; pain and difficulties with menstruation; urine retention; birth complications; and infections that can cause infertility, tumor, removal of uterus, urine retention and menstrual pain. Other associated psychological problems include trauma, stress, and family conflict. According to data from SOS Children Hospital abnormal birth rate was at 12.5% (out of 3223 births between May to October 2014), however these complications could not be directly attributed to FGM alone. The severe effects of FGM on the health of girls and women have been widely documented (World Bank, 2004). Similarly, in a study done by Yasin et al. (2013), FGM was associated with a series of health risks and consequences including pain, bleeding, difficult in passing urine, infection, death and hemorrhage. According to the World Bank (2004) long-term consequences of FGM include infibulation cysts, keloid scar formation, damage to the urethra resulting in urinary incontinence, pain during sexual intercourse, sexual dysfunction and difficult in childbirth, difficult menstrual periods among others. Similar complications including bleeding, infection and painful coitus were identified in a study by Dike et al. (2012). According to UNFPA, 2010, FGM has both immediate consequences including severe pain, shock, hemorrhage, tetanus or infection, urine retention, ulceration of the genital region and injury to adjacent tissue, wound infection, urinary infection, fever and septicemia. Hemorrhage and infection can be of such magnitude as to cause death and long-term consequences include anemia, the formation of cysts and abscesses, keloid scar formation, damage to the urethra resulting in urinary incontinence, dyspareunia (painful sexual intercourse) and sexual dysfunction, hypersensitivity of the genital area.
5.1.1.1 Action taken on health complications associated with FGM
Actions taken by the women to reduce the effects of FGM complications included mainly seeking medication; taking pain killers and community awareness to stop FGM. This finding was similar to that in a study done by Ahmadu (2007) where some of the popular interventions employed to reduce the effects of FGM complications included; health risk information, conversion of exercisers, training of health professionals as change agents, alternative rites programs, and community led approaches, public statements and legal measures. In this study, some women were not advised on what to do about the complications. Apart from self, women were mainly advised on how to handle FGM complications by health workers. Trained staff can recognize and manage the physical, sexual and psychological complications of FGM (World Bank, 2004).
5.2 Conclusions
From the study findings and objectives the study concludes as follows:
Uncircumcised women were younger as compared to circumcised women. The education levels among circumcised and uncircumcised women were similar. Most uncircumcised women were single as a result of fewer men being interested in them for marriage. Family type and FGM practice were not associated.
FGM was widely known and practiced in Delta state. The commonly known and practiced FGM types in this state were Type 3 and Type 1. Anti-FGM interventions carried out by women organizations and media in this state although not very popular were succeeding in reducing FGM incidences, however circumcised women were more aware of these interventions than uncircumcised women.
FGM was practiced mainly in Delta State because of cultural and religious reasons such as to keep virginity and to get a husband in future. According to women in this State FGM does not prevent promiscuity; women who have not undergone FGM were perceived to be clean. Sunna circumcision was unsafe. There was a wide support of interventions geared towards stopping FGM since most women in this state call for a stop in all forms of FGM.
Women in Delta State perceive FGM to have associated health complications. The most common health complications associated with FGM experienced by women who have undergone FGM in Delta State included pain, bleeding, difficulties with menstruation, infections and among others. Most women seek medical attention to counter the effects of FGM. Health workers were the main source of health information regarding FGM complications in this state.
5.3 Recommendations
From the study objectives and conclusions the study recommends as follows:
- The government of Nigeria should sensitize the public on the illegality of FGM together with associated health risks. Specific law against female circumcision should be put in place and initiatives that prohibit the practice
- There is need to strengthen health institutions to properly deal with FGM associated immediate and long-term illness since its prevalence is still high; and to reduce occurrence of abnormal
- Since FGM has been shown to be slowly fading away as indicated by its high prevalence among the old as compared to the young women, there is need to continue with community awareness campaigns to ensure that young women do not continue with the practice especially on their girls. Community awareness should be adopted to reduce the rigidity of men to marry uncircumcised women.
- There is need to engage religious leaders, TBAs and health professionals in the anti-FGM interventions including campaigns. These persons are more influential and strategic in disseminating information that clearly differentiates religious and cultural practices; and also the short and long term health risks associated with
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