ºÚÁÏÍø

Female genital mutilation (FGM) also called female genital cutting (FGC) or female circumcision is a public health problem the world over. According to the World Health Organization, ‘it comprises 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’. It has not been shown to have any known health benefits. Rather, it has serious medical, social and psychosexual complications [1]. Although it is prevalent in Nigeria and other African countries, Middle East and Asia where about 200 millions girls and women are said to have been mutilated for cultural, psychosexual, sociological and religious reasons [2], the practice has found its way into the western world due to migration. Hence it is a global concern.

Although female genital mutilation originated from traditionalists and birth attendants in the community, the practice has over time gained the sympathy of the medical community due to the erroneous belief that it would be safer if medicalized. This has resulted generally in fears of difficulty in eradication of the practice. Therefore, the global community has declared a zero tolerance and instituted measures to stop healthcare workers from getting involved in this practice which has been shown to have no known medical benefit [1,3]. Although it is largely carried out on children for various (non-medical) reasons, the victims are left with devastating long-term complications which tremendously affect the quality of life of affected persons in adolescence, adulthood and throughout the childbearing period of life. Worse still, because it is carried out among young girls who lack the capacity to give consent, the practice is considered a violation of human right, gender inequality and discrimination against women [1].

Based on the extent of the cutting of the genitalia female genital mutilation is categorized by the World Health Organization (WHO) into 4 types viz:

Type 1 – also called clitoridectomy, refers to the partial or total removal of the clitoris. This includes removal of the prepuce of the clitoris, removal of both the prepuce and the glans (also called circumcision or sunna) or removal of the entire clitoris.

Type 2 – refers to removal of clitoris together with partial or total removal of the libia minora with or without excision of the labia majora. It is the commonest form of FGM (accounting for up to 80% of the procedures) practiced globally and also in Nigeria [4].

Type 3 – also called infibulations or Pharaonic circumcision, this refers to the narrowing of the vaginal opening (introitus) by creating a covering seal formed by cutting and stitching part of the labial majora together leaving only a small opening for urination and menstruation. This covering will need to be opened up (deinfibulation) later in life to allow intercourse or to facilitate childbirth. This is the most extreme (severe) form of FGM accounting for about 15% of all procedures.

Type 4 – refers to all other procedures such as pricking, piercing, incising, scrapping and cauterizing of the female genitalia. Other forms include stretching of the clitoris or labia, scrapping of the vaginal orifice (angurya cut) or making incision on the vagina wall (gishiri cut) for treatment of dysmenorrhoea, infertility, uterovaginal prolapse, prolonged labour and insertion of corrosive substances into the vagina to tighten it [5].

These procedures are usually carried out by famous traditional cutters (circumcisers) in the communities, traditional birth attendants, grandmothers and in some cases, nurses/midwives.

Female genital mutilation is an ancient practice. Although the origin is unclear, the history of the practice is reported to be dated back to over 2000 years [6]. Some historians believe it originated in ancient Egypt as evidenced by some Egyprian mummies who were found to have undergone infibulalation [6]. Also, in some communities till date, a particular type of FGM is referred to as Pharaonic circumcision depicting Egyptian origin. According to the 6th century A.D. Greek physician Aetios, the cutting was necessitated by an enlarged clitoris in a girl which was viewed not only as a deformity and shameful but also capable of stimulating sexual desire by its continual rubbing on clothings [7].

Some others believe the practice started during the slave trade when black slave women were subjected to circumcision and infibulations to control their sexuality as well as to prevent conception. These practices were believed to provide better offers thereby enhancing the trade. Others believe the practice originated among some ethnic groups in sub-Saharan Africa as part of puberty rites to reduce a young woman’s sexual desire thereby preserving virginity [6].

Despite widespread condemnation, there are still reports of this practice in different communities across the globe. The practice has been reported in the western world where it is being done for conditions such as hysteria, masturbation and nymphomania [7]. In 2017, a Michigan doctor was arrested and charged with carrying out FGM on girls aged six to eight years [8]. There is now increasing legislative actions in parts of sub-Saharan Africa where the practice is prevalent. In Somalia which has the highest rate of FGM in the world – about 98%, the go vernment achieved the first conviction against practitioners of FGM in July 2018 after a 10 year-old died of complications of the procedure.

There are about 200 million girls and women who have undergone FGM in over 30 countries of the world where the practice is prevalent, mainly in Africa, Middle East and Asia [9]. According to the United Nations Children’s Fund (UNICEF), Somalia has the highest percentage (98%) of women aged 15-49 years who have undergone female genital mutilation. This is followed by Guinea (96%), Djibouti (93%) and Egypt (91%) [10]. FGM is also prevalent in Nigeria, Sudan, Central African Republic, Mali and Northern part of Ghana. In East African countries such as Somalia, Djibouti, Ethiopia, Sudan and Eritrea, infibulation which is the most severe form of FGM is mostly practiced. In contrast however, in West African countries such as Guinea, Mali, Burkina Faso, the tendency is to remove the clitoris and/or the labia minora without sewing the labia majora together [9].

Nigeria due to its vast population is said to have the highest number of absolute cases of FGM in the world, accounting for one-quarters of the estimated 200 million circumcised women in the world [11]. Although, the national prevalence of FGM in Nigeria was previously put at 41% among adult women [12], according to the Nigeria Demographic and Health Survey (2013), 25% of Nigerian women aged 15-49 years are circumcised. Although knowledge of FGM is higher among Yoruba women than those in any other ethnic group in Nigeria, it is most prevalent among Yoruba women (55%) in South-West Nigeria, followed by Igbo women (45%) in South-East Nigeria. Osun State has the highest prevalence (77%), followed by Ebonyi (74%) and Ekiti (72%). Katsina has the lowest prevalence (0.1%) [13]. Prevalences of 13% and 34% have been reported respectively from Kano and Kaduna both in North-West Nigeria [14,15] Other authors have reported prevalences of 49.6% and 48.5% in South-East Nigeria [16,17]. These show that female genital mutilation is more widespread in the Southern part of Nigeria compared to the Northern part, although the more severe forms such as Angurya, Gishiri cut and the use of corrosive substances to tighten the vagina are practiced there [12,13]. For instance, infibulation is most prevalent in Nasarawa (22%) and Kaduna States (21%) in North-Central and North-West Nigeria respectively followed by Bayelsa (20%) in South-South Nigeria [13].

The reasons for performing female genital mutilation are varied. They range from hygiene and aesthetics to psycho-sexual, sociocultural and religious [18]. FGM is seen as a rite of passage or initiation into womanhood. It is usually done at puberty just before menstruation or marriage. In some communities, a girl is unfit for marriage until FGM is done. It extreme cases, it is both a stigma and a taboo for a girl to get married without being cut as the practice is believed to preserve virginity before marriage. FGM is thus believed to confer better marriage prospects to the girls who have been cut [18,19].

In some traditions in Nigeria, women are considered emotionally weak and are unable to control their sexuality. FGM is employed as a tool to effectively control women’s sexuality and ensure chastity, thereby preventing premarital sex and ensuring a woman’s faithfulness to her husband [20]. In addition, the practice is perceived to result in increased sexual satisfaction for the husband [21]. FGM is also believed to confer gender identity. It is carried out to differentiate a male from a female child. The clitoris is considered a masculine structure so the removal in a girl child is advocated to confer feminity [19].

Among some societies, the female external genitalia is considered unclean and unsightly. Some parts are therefore excised to promote hygiene and provide aesthetic appeal. FGM is practiced in a number of communities, under the mistaken belief that it is demanded by certain religions although is not required by any. It is also perceived to enhance fertility, aids childbirth and promotes child survival. In some parts of South-West Nigeria, the clitoris was considered dangerous. It was believed that at childbirth, if the head of the baby touches the clitoris, the baby would die [19]. This explains while the practice is prevalent among the Yorubas of South-West Nigeria, though with the exception of the Ijebus who are reported to be absolutely averse to the practice [22]. In other communities, the genitalia is cut to ensure her future spouse would survive [19]. In a study in South-East Nigeria, the reasons for FGM are prevention of promiscuity (38.3%), cultural beliefs (27.5%), hygiene (4.4%), promotion of future childbirth (1.8%) and religion (1.2%) [23]. In another study done in Benin-City, religiocultural and superstitious beliefs were the main reasons for FGM [24]. The study in Kano, North-West Nigeria, reported tradition/culture as the commonest reason for FGM accounting for 73.1%. Other reasons included were religion in 11.5%, hygiene in 11.5% and preservation of virginity in 3.8% [14].

FGM has not been shown to confer any known health benefits. Rather, it is associated with serious medical and psychosexual complications. Complications of FGM could be immediate, short-term or long-term [21].

Immediate complications include severe pain as the procedures are carried out without anesthesia, haemorrhage and shock either from the pain or excessive blood loss and death if the shock is not promptly managed [21]. During the procedure there may be injury to nearby structures such as the urinary bladder or urethra. After the procedure, the girls may experience painful urination and vesico-vaginal fistula from trauma to other genitourinary organs [25-27]. For instance, Gishiri cut is a documented cause of vesico-vaginal fistula in Northern Nigeria [28].

Short-term complications include wound infection, sepsis, urinary tract infection, tetanus, hepatitis B infection and HIV/AIDS as a result of use of unsterilized instruments [21]. Others are clitoridal cyst, labial adhesions following healing of the genital wound [23].

Long-term complications are far-reaching and usually impair the quality of life of the woman up to her childbearing years and even beyond. The women suffer serious psychological problems, reduced sexual desire, marital disharmony and emotional trauma. When they eventually commence sexual activity, many of them experience coital bleeding, painful intercourse, inability to engage in sexual intercourse, chronic pelvic pain, infertility and gynaetresia. FGM also has a number of obstetric complications such as difficult/obstructed labour, increased need for episiotomoy, increased need for caesarean section, postpartum haemorrhage and perinatal death [25-27]. The women are also at risk of developing obstetric fistula (vesico-vaginal or recto-vaginal fistula) which is one of the most devastating conditions affecting women in low- and middle-income countries [25-29].

In 2008, the 61st World Health Assembly mandated member states to take actions to eliminate FGM and provide support for victims [30]. WHO in 2010 in conjunction with UNESCO launched a global “demedicalization campaign” strategy; aimed at coordinating the efforts of policy makers, international agencies, professional bodies, community leaders, religious leaders and Non-Governmental Organizations to stop healthcare providers from performing FGM [31]. Also, the 6th day of February each year has been adopted by the UN as the International Day for Zero Tolerance for FGM in 2012 [32].

In 1994, Nigeria joined other members of the 47^th World Health Assembly and resolved to eliminate FGM [21]. Also, the Violence against Persons Prohibition (VAPP) Act, 2015 came into force on 25th May, 2015 as the first federal law criminalizing FGM in Nigeria. The law aims to eliminate gender-based violence in private and public life by criminalizing and setting out the punishment for acts including rape, incest, domestic violence, stalking, harmful traditional practices and FGM [33]. Although the VAPP Act was initially effective only in the Federal Capital Territory, 13 out of 36 states of the federation currently have legislation prohibiting the practice. Beyond legislation, there is need for strict enforcement of the law in these locations to secure convictions as a deterrent to adherents of this violation of human rights. Although, intersectoral collaboration among government agencies such as the Ministry of Women Affairs and Social Development, Ministry of Information and Culture, Ministry of Justice, Ministry of Health and the National Human Rights Commission is already in place [26], this should be encouraged by the Federal Government of Nigeria to strengthen the campaign against FGM. Elimination of FGM in Nigeria will also require continuous and aggressive sensitization of policy makers, general public, religious and traditional leaders, health workers and the practitioners on the problems associated with this dehumanizing practice [21].

The practice of FGM is enshrined in cultural and traditional beliefs within a frame of sexual, moral and religious factors that are sustained through community mechanisms, all of which can be mitigated by legal framework and national discourse [34]. In Nigeria, attempts at total eradication are being resisted by misconceptions and deeplyrooted cultural beliefs and practices that allow the perpetuation of the practice. Education and behavioral change at all levels are needed to overcome this resistance. Also, continued sensitization of key stakeholders, legislation across the entire country and formation of wider global networks are required in the fight against the menace of FGM.