Editor’s note: This article first appeared in Midwifery Today, Issue 120, Winter 2017.
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A few years ago, I sat down to talk with a midwife who had returned from West Africa to Wheaton, Illinois. She told me about a night in the village where she served when approximately thirty prepubescent girls, between the ages of five and ten, were ritually cut by a man, a visiting “circumciser,” all with the same knife, one after another, without any kind of painkiller. Their screams filled the night air. As soon as she could, the very next day, the midwife got to each girl, assessed the damage and did repairs. Because she was in a remote location, without sufficient suturing supplies, she told me, “I was sewing them up with dental floss.” I will never forget my sister-midwife’s weariness or the memory of trauma that lingered within her as she leaned her head into her right hand and closed her eyes as she finished telling me this.
Others have made this point before, but it bears repeating: Female genital mutilation takes place in the developed world on a large scale in the form of medically unnecessary episiotomies and caesarean sections, or what could be classified as FGM Types 5 and 6.
Definitions and Complications
According to the World Health Organization, cutting or female genital mutilation (FGM) includes procedures that intentionally alter or cause injury to female genitalia for non-medical reasons. FGM is classified into four types:
Type 1: Often referred to as clitoridectomy, this is the partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals), and in very rare cases, only the prepuce (the fold of skin surrounding the clitoris).
Type 2: Often referred to as excision, this is the partial or total removal of the clitoris and the labia minora (the inner folds of the vulva), with or without excision of the labia majora (the outer folds of skin of the vulva).
Type 3: Often referred to as infibulation, this is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoris (clitoridectomy).
Type 4: This includes all other harmful procedures to the female genitalia for non-medical purposes, e.g., pricking, piercing, incising, scraping and cauterizing the genital area.
The WHO recognizes that there are no health benefits, only harm, caused by these procedures. Complications include severe pain, excessive bleeding (hemorrhage), genital tissue swelling, fever, infections, urinary problems, wound healing problems, injury to surrounding genital tissue, shock and death. Long-term consequences include urinary, vaginal, menstrual, sexual and psychological health issues (including anxiety, depression and PTSD) as well as complications in childbirth. Infibulated women must undergo subsequent surgeries in order to experience sexual intercourse and childbirth. The risk of tearing and excessive bleeding, and the risk of death in childbirth for both mother and baby, is increased (WHO FGM Fact Sheet 2016).
As researcher Patricia Diane Raya has noted, in a study involving 28,393 genitally mutilated African women, “The Lancet reported that these women, particularly those who were infibulated, experienced a higher rate of infant mortality, a 30 percent increase in caesarean section, 70 percent increase in after birth hemorrhage, and an increased need to resuscitate babies. The study also determined that one or two neonate deaths per 100 deliveries were prevalent in this population of women” (2010, 303).
Episiotomy and Caesarean
Others have made this point before, but it bears repeating: Female genital mutilation takes place in the developed world on a large scale in the form of medically unnecessary episiotomies and caesarean sections, or what could be classified as FGM Types 5 and 6. These kinds of cutting come with immediate risks and long-term consequences as well. It is useful to keep in mind the incredibly influential (albeit inaccurate) beliefs in our culture are used to justify the continued, widespread practice of episiotomy and c-section, even though evidence-based research clearly demonstrates how very rarely either of these is truly needed to off-set a more severe complication.
Cliteridectomies and removal of the ovaries, performed in medical clinics and hospitals, has a history in the United States as well. Until the 1950s, these were considered an option to treat “masturbation, epilepsy, nervous disorders, nymphomania, melancholia, hysteria, and lesbianism, and to prevent divorce” (Raya 2010, 304–05). Apparently, Blue Cross-Blue Shield insurance company covered female circumcision until 1977 (Raya 2010). Although the United States outlawed these forms of cutting in 1996, FGM is still practiced illegally at times. Few, if any, legal restrictions have been applied to medically unnecessary episiotomies and cesarean sections.
By reflecting on our own past and present cultural myths about the supposed medical necessity of cutting, we may understand better the cultural beliefs that perpetuate cutting/FGM Types 1–4 in places around the globe.
Prevalence and Beliefs
The practice of cutting is widespread in western, eastern, and north-eastern regions of Africa; in some countries in the Middle East and Asia; and also among immigrants from these places. There are 200 million girls and women alive today who have experienced FGM (WHO FGM Fact Sheet 2016). This is true even though cutting is often against the law in the 30 countries where cutting is most commonly practiced. That’s because the law is not known, and where it is known, it is not enforced. Local custom trumps national policy.
Sometimes it is mothers who bring their daughters to a local or traditional midwife-circumciser to do the cutting. Why?
- Because they share a cultural belief that a girl’s virginity, marriageability and sexual fidelity to her future husband are contingent upon cutting;
- Because cutting is traditional and expected, a sign of cleanness or femininity and/or a social requirement for continued inclusion in the community;
- Because it was done to them and therefore they do it to their daughters.
The cycle is perpetuated over and over again. But some people inside and outside of these communities are seeking to eliminate the practice.
Prevention and Intervention
The most effective way to eliminate cutting in a community where it is practiced is for the people within that community to decide they no longer want it. When people change their beliefs, it is a short step for them to change their practice. Does this actually happen? Yes, it does. Through education and courageous action, cutting can be stopped.
Partnerships are key, and they can be formed between many different agents of change. Girls who have been cut can heal, growing from victims to survivors to overcomers, and they can use their voices and share their stories in ways that shift attitudes in their communities. Instead of perpetuating the violence in the next generation, they stop cutting. High-profile supermodels like Iman, the wife of the late musician David Bowie, and Waris Dirie, both immigrants to the UK from Somalia, are two fairly well-known examples of agents of change (Neustatter 1998). These survivors became outspoken advocates for the bodily integrity of girls and against female genital mutilation.
Religious and social leaders in cutting communities can take a stand against the practice. In Burkino Faso, 18,000 people renounced the practice of cutting when three men—their tribal chief, an imam, and a Christian priest—announced that the practice was forbidden. These men had been persuaded to take this action by Somalian Fadumo Korn, an advocate campaigning against FGM internationally. Her work was funded by Nala, an NGO in Germany (Gehrke 2013). This is precisely the kind of partnership that works: one that takes time, energy and cooperation, and secures the commitment of all involved.
If there is a so-called “circumciser” in the community who usually does the cutting, that person must stop and be given other work to do. If there are no national policies against FGM, these must be formulated; once legislated, communities must be educated about them. Then, of course, if the practice continues, the law must be enforced, so the cutting won’t continue.
When everyone affected—girls, their families, local leaders, national policy makers, law enforcement, native and international educators and international donors—form partnerships to stop cutting, cutting stops.
Educators and Healers
Midwives can help to stop the practice of cutting in their role as educators, and they can help to heal the painful effects of it physically, psychologically and communally. My sister-midwife, who served a remote village in a West African country, brought a skill no one else there had in order to serve girls who had been cut: the skill of suturing. Because she knew how to suture well, even without sufficient supplies, she began the physical healing process by cleaning and sewing the injured girls within hours of the assault. Later, as an educator, she began to raise awareness in others, like me, of the need for change simply by telling her story.
It is important to note that the injuries my friend repaired went well beyond first and second degree perineal tears. The repairs she performed required advanced knowledge, skill and effort. But this nurse-midwife had not let someone else’s conception of what her scope of practice should be keep her from learning what she needed to know to serve effectively in her adopted West African village. How many midwives fail to learn even the basics of suturing second-degree tears? Women have the right to bodily integrity, but if it is not honored, they deserve to have skilled midwives who can suture well, listen well and advocate well for them.
Midwives in the US, the UK, and the UN may increasingly find they need to help immigrant women in childbirth who have been cut. It’s important to learn how. It’s important to train others. For just as birth is a human rights issue, so is the right to bodily integrity. When the integrity of the body is violated, healing is paramount. If good midwifery care is, in part, about “mothering the mother,” then caring well for childbearing women who have been cut is part of our responsibility.
- Gehrke, M. 2013. “The Fight against Female Genital Mutilation.” DW. Accessed November 3, 2016. http://www.dw.com/en/the-fight-against-female-genital-mutilation/a-16576486.
- Neustatter, A. 1998. “It Cuts So Deep.” The Independent. Accessed November 3, 2016. http://www.independent.co.uk/arts-entertainment/it-cuts-so-deep-1151654.html.
- Raya, P. 2010. “FGM and the Perpetuation of Multigenerational Trauma.” The Journal of Psychohistory 37 (4): 297–325.
- WHO. 2016. “The WHO FGM Fact Sheet.” WHO. Accessed November 3, 2016. http://www.who.int/mediacentre/factsheets/fs241/en/.