THE PREVALENCE, SEVERITY AND RATIONALE OF THE PRACTICE OF FEMALE GENITAL MUTILATION AS SEEN IN BAPTIST MEDICAL CENTRE, EKU, DELTA STATE.
BY
DR OMU, EBIKEFE TARILAEMI B. Med. Sc (Anatomy), MB.BS. (UPH)
A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE FELLOWSHIP OF THE COLLEGE IN FAMILY MEDICINE.
NOVEMBER, 2010
CERTIFICATION
This is to certify that this work was carried out by DR EBIKEFE TARILAEMI OMU at the Baptist
Medical Centre, Eku Delta State under my supervision
SUPERVISOR
DR DIENYE, P.O. MBBS, FMCGP, FWACP CONSULTANT FAMILY PHYSICIAN AND DIRECTOR OF RESIDENCY TRAINING DEPARTMENT OF FAMILY MEDICINE UNIVERSITY OF PORT – HARCOURT TEACHING HOSPITAL PORTHARCOURT
Signature and Date……………………………………
2 DECLARATION
It is hereby declared that this work is original unless otherwise acknowledged. This work has not been presented to any other college for a fellowship nor has it been submitted elsewhere for publication.
SIGNATURE………………………………
DR OMU, EBIKEFE TARILAEMI B. Med. Sc (Anatomy), MB.BS (UPH)
3 DEDICATION
To the Almighty God who was, who is and is to come; and who granted me the grace and strength to complete the fellowship programme of the highly esteemed National Postgraduate Medical
College of Nigeria.
To my loving wife Esther Tamunotekena and my dear children Oyindiepreye Lydia and
Oyinkariebi David.
4 ACKNOWLEDGEMENT
I am indeed grateful to the Almighty God for making this work possible. Special thanks go to my supervisor Dr. P.O.Dienye for his conscientious supervision of this work. I am also thankful to Dr.
A.B. Akani for his encouragement and support.
My appreciation goes to the staff of the obstetrics and gynaecological unit of the Baptist Medical
Centre Eku for their support. I am indebted to all the resident doctors of the Baptist Medical Centre
Eku and Teaching Hospital Port-Harcourt for their encouragement and useful suggestions.
I am grateful to Mrs Nedie Akani for a thorough statistical analysis of the raw data.
My indebtedness also goes to all the members of my family for their prayers and encouragement.
5 TABLE OF CONTENTS
TITLE PAGE i
CERTIFICATION ii
DECLARATION iii
DEDICATION iv
ACKNOWLEDGEMENT v
TABLE OF CONTENTS vi-viii
LIST OF TABLES ix
LIST OF FIGURES x-xi
LIST OF ABBREVIATIONS xii
SUMMARY xiii-xv
CHAPTER ONE:
1.0 INTRODUCTION 1-4
1.2 DEFINITION OF TERMS 4-5
1.1 OBJECTIVES OF STUDY 6
1.2 JUSTIFICATION/RELEVANCE OF STUDY 6-7
6 CHAPTER TWO
REVIEW OF LITERATURE
2.0 STRUCTURE AND FUNCTION OF EXTERNAL GENITALIA 8-9
2.1 HISTORICAL BACKGROUND 9-10
2.2 HISTORY OF TERMINOLOGY 10-11
2.3 WORLD HEALTH ORGANIZATION’S CLASSIFICATION 11-13
2.4 EPIDEMIOLOGY OF FEMALE GENITAL MUTILATION 13
2.5 PREVALENCE AND DISTRIBUTION OF FGM 13-14
2.6 THE NATURE AND SCOPE OF FGM IN NIGERIA 14-15
2.7 REASONS FOR FEMALE GENITAL MUTILATION 15-26
2.8 HEALTH CONSEQUENCES OF FEMALE GENITAL MUTILATION 26-43
2.9 THE LEGAL STATUS OF FEMALE GENITAL MUTILATION 43-46
2.10 SECULAR TRENDS 46
2.11 EFFORTS AT ELIMINATION OF FEMALE GENITAL MUTILATION 46-49
7 CHAPTER THREE:
MATERIALS AND METHODS 50- 53
CHAPTER FOUR:
RESULTS 54-87
CHAPTER FIVE:
5.0 DISCUSSION 88-92
5.2 RECOMMENDATIONS 93-94
5.3 LIMITATIONS OF STUDY 95
REFERENCES 96-106
APPENDIX I ETHICAL CLEARANCE 107
II CONSENT FORM 108
III QUESTIONNAIRE 109-121
8 LIST OF TABLES
1. Age distribution and circumcision status of respondents…………………………………..57
2. Parity distribution and circumcision status of respondents…………………………………58
3. Social class distribution and circumcision status of respondents. …………………………59
4. Distribution of tribe and circumcision status of respondents………………………………60
5. Distribution of marital status and circumcision status of respondents...………………...... 61
6. Distribution of religion and circumcision status of respondents.……………………… …62
7. Distribution of educational status and circumcision status of respondents.………………..63
8. Distribution of circumcised respondents and age at circumcision……………………… …64
9. Distribution of respondents’ circumcision status and daughters’ circumcision status……...67
10. Distribution of respondents’ circumcision status and intention to circumcise daughters…. 68
11. Distribution of respondents’ support for ban of the practice………………………………..69
12. Distribution of respondents’ educational status and ban of practice………………………..70
13 Distribution of respondents’ social class status and ban of practice………………………..71
14 Distribution of relations who took respondents for circumcision…………………...... 72
15. Distribution of respondents and type of anaesthesia used…………………………………..78
9 LIST OF FIGURES
2.1 Diagram of the normal vulva………………………………………………………..11
2.2 Why the practice of FGM continues: Mental map…………………………………..22
4.1 Physiological status of respondents in percentages………………………………… 56
4.2 Overall prevalence of circumcision in this study …. ……………………………….63
4.3 Prevalence of the type of mutilation…………………………………………………65
4.4 Frequency of respondents by educational status citing tradition as reason
for circumcision...... 66
4.5 Percentage of circumcised respondents and consent obtained…………………….. .73
4.6 Percentage of circumcised respondents and occupation of circumciser……………. 74
4.7 Percentage of circumcised respondents and instrument used………………………. 75
4.8 Percentage of circumcised respondents and knowledge of sterility of instrument used……………………………………………………………………………
…….76
4.9 Percentage of circumcised respondents and use of anaesthesia………………………77
4.10 Percentage of circumcised respondents and duration of procedure…………………79
4.11 Percentage of circumcised respondents and material used to arrest bleeding………80
4.12 Percentage of circumcised respondents and venue of procedure……………………81
4.13 Percentage of circumcised respondents and facility of circumcision…………………82
4.14 Reasons given for circumcision by circumcised respondents………………………..83
4.15 Frequency of immediate complications among circumcised respondents…………....84
4.16 Percentage of gynaecological complications among respondents…………………...85
4.17 Percentage of obstetrics complications among respondents………………………....86
10 4.18 Percentage of psychological complications among respondent…………………….. 87
4.19 The frequency of respondents intention to circumcise daughters and educational level…………………………………………………………………….87
11 LIST OF ABBREVIATIONS %……………………percent A.D…………………Anno Domini (After the death of Christ) B.C………………….Before Christ C.I…………………..Circumcision Index d…………………….precision limit. FGC…………………Female genital cutting FGM………………..Female genital mutilation FIGO……………….Federation of International society of Gynaecology and Obstetrics gm%………………..gram percent gm………………….gram Hb …………………Haemoglobin HIV…………………Human immunodeficiency virus HTP………………..Harmful traditional practices IAC…………………Inter-African Committee IUCD……………….Intrauterine contraceptive device mg…………………..milligram mmHg………………millilitres of mercury η…………………….Sample size OR…………………..Odds ratio P…………………….prevalence q…………………….1-prevalence STI………………….Sexually transmitted infection UNFPA……………..United Nations Population Fund UNICEF…………….United Nations Children’s Emergency Fund UTI………………….Urinary tract infection VVF………………...Vesico-vaginal fistula WHA………………..World Health Assembly WHO……………….World Health Organization X2 …………………..Chi-square Zα…………………..Level of significance
12 SUMMARY
A cross sectional study of the prevalence, severity and rationale of the practice of female genital mutilation was carried out at the obstetrics and gynaecological clinic of the Baptist Medical Centre,
Eku from September 2002 to February 2003. It focused on females alone because they are the victims of this practice.
Data was collected using a pre-tested structured questionnaire interviews to determine the background sociodemographic characteristics of respondents, attitudes and clinical effects. A physical examination was done by the investigator by inspecting the vulva to confirm presence or absence of FGM using the
WHO classification.
A total of 384 clients were involved aged 15 to 49 years with a mean age of 30.41 ± 6.36years. Out of the 384 clients, 226 (58.9%) were of the Urhobo tribe. Three hundred and seventy (96.4 %) out of the
384 clients were Christians. Ninety four (24.5%) were non pregnant and 290 (75.5%) were pregnant.
Two hundred and eighty two clients out of 384 were mutilated, giving a prevalence rate of 73.4%.
Ninety-three (24.2%) of the mutilated women intended to circumcise their daughters.
The commonest mutilation was type I 200 - (70.9%). Type II was 78(27.7%) and type III - 4(1.4%).
There was no case of type IV.
The commonest age at circumcision was 10-19 years -178(63.1%). Two hundred and thirty three (82.6%) of the clients’ mothers took their children for the procedure. Consent was obtained in only 147(52.1%) of clients before the procedure was performed on them. One hundred and ninety two (68.1 %) of the procedures were carried out by females among whom 151(53.5%) were trained nurses. Medical doctors performed eight (2.8%) cases. The commonest instrument used for
13 circumcision was scissors in 99 (35.1%) of cases. Cotton wool and gauze were the commonest materials used to arrest bleeding in 157 (55.7%) of cases.
One hundred and forty seven (52.1%) of the procedures took place at home and 128 (45.4%) in the hospital. Local anaesthesia was used in 162 (57.4%) of cases and the duration of the procedure lasted for ten minutes in 58 (20.6%) of cases. Twenty-five (8.9%) of the circumcisions were done in pregnant women.
The commonest reason for circumcision was tradition in 208 (73.8%) of cases and the commonest immediate complication was pain in 102 (36.2%) of cases. Fifty-four (19.2%) of the circumcised respondents had gynaecological complications and the commonest was infertility in 21 (7.4%) respondents. This was also the commonest complication in the uncircumcised women - 9 (8.8%).The difference was not statistically significant (p=0.657). Fifteen (5.32%) of circumcised women had obstetric complications and the commonest was fresh stillbirth in six (2.1%) due to prolonged labour.
Nine of the uncircumcised women had obstetric complication. One hundred and forty one of those circumcised had psychological complications and the commonest was lack of sexual satisfaction.
Three hundred and four (79.2%) of the clients supported the ban of the practice and the reason for doing so was because of its complication in 191 (49.7%) of clients. Educational exposure and attainment appeared to have a positive impact on refusal to practice FGM (p< 0.05). Women of low socioeconomic status were more favourably disposed to practicising this tradition than the elites (p
<0.05). It was concluded that female genital mutilation is a prevalent condition and that there was no significant association between gynaecological complications and female genital mutilation but a
14 significant association between obstetric and psychological complications and female genital mutilation.
It is therefore recommended that efforts should be made by health care practitioners to educate women in the obstetrics and gynaecological clinics about the detrimental effects of female genital mutilation.
This effort should also extend by way of enlightenment to the traditional institutions who are the custodians of culture in the village.
15 CHAPTER ONE
INTRODUCTION
Female genital mutilation (FGM) commonly, but incorrectly known as female circumcision (FC), according to the World Health Organization’s definition encompasses a number of traditional operations that involve cutting away parts of the female external genitalia or other injuries to the female genitals, whether for cultural or any other non-therapeutic reasons 1-6.
Female genital mutilation is practiced in one form or another in twenty-eight nations in the African
Continent, in a few countries on the Arab peninsula (parts of Oman, United Arab Emirate and Yemen), among some minority communities in Asia including Malaysia and Indonesia and among immigrants from these areas who have settled in Europe, Australia and North
7-10 America .
There is evidence that this harmful traditional practice (HTP) existed before Christianity, Islam or
Judaism began. It is as old as the pyramids of ancient Egypt 11, 12.
There are four types of FGM operations as defined by WHO based on the extent of amputation of the tissues 13-16. These are type I (Sunna) – excision of the clitoral hood (prepuce) with or without partial or total clitoral excision, type II - total clitoral excision with partial or total excision of the labia minora, type III – (infibulation, Pharaonic): partial or total excision of the external genital (clitoris, labia minora and labia majora) and stitching and /or narrowing of the vaginal opening, type IV – (unclassified): all other operations on the female genitalia including introcision (e.g. Gishiri cuts), piercing or incising the clitoris and/or cutting of the vagina, introduction of corrosive substances and herbs into the vagina with the aim of tightening it. Types I and II belong to a broad group called clitoridectomy (reduction
16 operation) and type III to infibulation (covering operation). The relative distribution of clitoridectomies and infibulation is not well documented. A crude estimate of eighty to eighty-five percent clitoridectomies and fifteen to twenty percent infibulation or a ratio of 4:1 is made based on review of both statistical and non-statistical data 2,5,7,14-21.
It is estimated that 100 to 140 million women now living have undergone the procedure 2, 4, 6, 8, 18, 21-24. At least three million girls a year are at risk of genital mutilation – approximately 6,000 per day or five every minute 6, 16, 18, 25-28.
The variation in prevalence between countries ranges from five percent in Uganda and Zaire to almost ninety-eight percent in Somalia and Djibouti 12, 23. The most severe forms are observed among Somalis and Sudanese populations 9, 12, 29.
With an overall national prevalence of fifty percent, Nigeria has the highest absolute number of genitally mutilated women throughout the world 2, 10, 13, 30. The prevalence ranges from 0% in parts of
Kogi and Ogun states to 100% in Benue and kebbi States 2. In some parts notably Osun, Oyo, and Edo states, the prevalence of FGM among women of reproductive age exceeds ninety percent 2. In the
Southern parts of Nigeria where Types I and II are found mainly, it is prevalent in Akwa Ibom, Cross
River, Delta, Anambra, Imo, Ondo and Rivers states. Type III can be found among the Igbos in Imo state and girls from Edo and Delta states. Type IV is generally practiced among Hausas in Kaduna and
Katsina in the Northern States of Nigeria 12.
The age at which FGM is performed varies widely depending on the Ethnic group and geographical location 9, 31. In some groups, it is performed on babies, while in others, it is performed in menarche, pregnancy or childbirth. In other communities if a woman escapes being circumcised during her life,
17 when she dies, she is not spared from this procedure if she is to receive a decent burial. However, the
22, 26, 31, 32 procedure is more commonly undertaken between the ages of four and ten years .
The operation, which lasts for about fifteen to twenty minutes, is normally carried out with special knives, sharp stones, scissors, scalpels, and pieces of glass or razor blades 15, 32, 33. The instruments are often not sterilized. Anaesthetics, antiseptics and analgesics are usually not used 27, 34 and pastes containing herbs, cow dung, local porridge, ashes, barks and roots of trees are frequently rubbed on the wounds to stop bleeding 12, 35. The procedure is usually undertaken by elderly women in the community specially designated for this task or by traditional birth attendants12, 35.
However, some orthodox health practitioners such as midwives and doctors have been known to carry out this procedure 16, 21, 25, 28, 29, 36, 37.
Advocates and practitioners of FGM often cite its value as the initiation rite into womanhood, restriction of female sexual desires and preservation of virginity, prevention of promiscuity and infertility, the maintenance of hygiene and cosmetics 5, 14, 38. Men have been known to refuse marriage to women not yet circumcised. Interestingly, women are often the strongest proponents of the procedure as the rejection of FGM may carry with it a potential loss of status and acceptance within the community 3, 24. In addition those who perform FGM advocate strongly for its continuation because it provides them a ready source of income as well as a status symbol 19, 23, 24, 30.
The health consequences are both immediate and life-long 5, 9. These complications may be psychosexual and physical. The complications of circumcision can be detected and treated in gynaecological and antenatal clinics. The psychosexual consequences have not been
18 well-studied 1, 8 11, 21, 26, 30, 39 - 41. The physical complications are well documented and common to all
7, 8, 39, 40 types of FGM but worse with infibulation .
The eradication of FGM requires a global action. This can be achieved through education, advocacy, legislation and research 5, 19.
Advice against female circumcision can become part of comprehensive reproductive health information and counseling package delivered through oral, written or audio-visual media 40, 42.
DEFINITION OF TERMS:
1. SOCIO- ECONOMIC STATUS
The social class (or socio –economic status) of the women was obtained through a scoring system
(index) combining the women’s level of education with thei husband’s occupation.
This allocated each woman to social class I to V, social class V being the bottom of the social stratification. The suitability and application of this social classification system for our environment
43 has been well tested .
THE SCORING SYSTEM OF SOCIAL CLASSIFICATION.
Indices Score
A. Husband’s occupation
Professional 1
Middle level 2
Unskilled 3
19
B. Woman’s Education
University 0
Secondary/ Postsecondary (Below university) 1
Primary/Nil 2
Each woman’s social class (1-V) is obtained by adding the scores from A and B above.
2. CIRCUMCISION INDEX: This is the ratio of circumcised to uncircumcised respondents. It is an age related measure of the trend of circumcision
3. HARMFUL TRADITIONAL PRACTICES - This is a general term used to describe acts based on culture, beliefs and norms that have been passed from generation to
generation 16, 40, 42, 44.
These include: i FGM ii Nutritional taboos iii Seclusion in labour iv Child marriage and teenage pregnancy v Gishiri cut vi Hot puerperal bath vii Male child preference
20 viii Clitoral massage with vaseline
1.1 OBJECTIVES OF STUDY
General:
To determine the prevalence of FGM in Baptist Medical Centre, Eku, Delta State
Specific:
1. To determine women’s’ attitudes and practices towards FGM
2. To determine the physical and psycho-sexual complications of FGM
3. To determine the type or types of FGM practiced
1.2 RELEVANCE/JUSTIFICATION OF STUDY
Female genital mutilation has been practiced in various parts of Nigeria over several generations.
However, it was only recently that its adverse effects on women’s reproductive health began to receive attention.
A female worker in the Hospital under study who is an indigene of Eku invited the investigator to the circumcision ceremony of her daughter and refused to be convinced that it is a harmful practice. In this same Hospital, in the course of examining female clients at the antenatal and gynaecological clinic, a number of genitally mutilated women were seen with various complications such as keloid, clitoral cyst, dyspareunia, and infertility. This study focused on females because they are the victims of this harmful practice and, as mothers, their attitudes towards FGM will go a long way in determining the success of any control measures. Increased education and public enlightenment on the risks and numerous disadvantages of FGM are expected to reduce the practice, but there are still major gaps in
21 knowledge about the extent and nature of the problem and the kinds of intervention that can be successful in eliminating it.
The Family Physician has a number of roles to play in the eradication of female genital mutilation.
These include: Treatment of complications, health education of individuals and families and research to find effective interventions to eradicate the practice. Therefore, the family Physician should look out for genital cutting and its complications while doing vaginal examination on any girl or woman and treat and /or counsel such women appropriately. He may mount health education posters in his office and may through counseling influence key or dominant decision-makers in the families as they come for treatment or call for interviews with family decision-makers as and when necessary – promoting health by a good patient-doctor relationship that must have resulted over the years.
Furthermore, the Family Physician may notify appropriate quarters of the incidence rate of FGM and its complications in his locality. The public health physician may thereby be mobilized for effective community action.
Similar studies have been conducted at Abia state University13 and Amino Kano Teaching Hospital in
Kano State of Nigeria45 but no such study has been carried out at the Baptist Medical Centre, Eku. All these have stimulated this study to document every aspect of the practice in order to provide a framework for target interventions to eradicate the practice. It is hoped that the knowledge derived from this study will be useful:
1. As a background information on which further studies which may be community based will be
done
22 2. As a basis for health education of women of reproductive age in the antenatal and
gynaecological unit about the ills of female genital mutilation.
3. As a basis for planning for the healthcare needs of those already mutilated.
23 CHAPTER TWO
REVIEW OF LITERATURE
2.0 Structure of normal external female genitalia46:
The female external genitalia consists of the Skene’s and Bartholins glands, the vaginal orifice, the urethral meatus, clitoris, labia minora, labia majora and perineum
Structure and functions of external female genitalia
Figure 2.1
Structure Functions
Skene’s and Bartholins glands - lubrication of the vagina
Vaginal orifice - Allows escape of menstrual flow, sexual intercourse and delivery of baby.
Urethral meatus - Allows emptying of the bladder.
Clitoris - Assists women to achieve sexual satisfaction.
24 Labia minora - Protects structure and orifice.
Labia majora - Protects the inner structure and orifice.
Perineum - Supports the pelvic organs and separates vagina from anus.
2.1 HISTORICAL BACKGROUND:
Female genital mutilation (FGM) variously referred to as female circumcision or female genital cutting is a form of violence against women 35, 45, 47. It constitutes all procedures, which involve the partial or total removal of the female external genitalia or other injuries to the female genital organs whether for cultural or any other non-therapeutic reasons. The practice of female genital mutilation is widespread and remains a major cause of morbidity and mortality worldwide 48. It is a tradition that transcends religion, socioeconomic status and geography 8, 19, 48-52.
According to WHO, the practice of FGM is closely associated with poverty, illiteracy and the low status of women 16, 23.
It is not known when or where the tradition of FGM originated but according to the famous historian
Herodotus, it dates back to the 5th century B.C and was practiced by the Phoenicians, Hittites,
Ethiopians and Egyptians9, 10. A later reference to the practice, found on a Greek papyrus in the British museum dated 163 BC, mention girls being circumcised at the age they received their dowries.9, 10.
Female genital cutting has been practiced in various forms in various parts of the world and is still widely practiced today 21, 50.
FEMALE GENITAL MUTILATION IN MEDICAL PRACTICE
In the 1870s, and as recently as the 1940s, clitoridectomy (along with oophorectomy) was in the United
States and Britain, the treatment for a variety of female ailments including hysteria, melancholy,
25 epilepsy, lesbianism and masturbation.32, 45, 52- 55. Physicians have also incised the clitoral prepuce to treat frigidity and have performed aesthetic labioplasties to reduce the size of the clitoris and labia14,
19.
It has been argued that the practice had its origin in the male desire to manipulate women’s sexuality, ensure their subjugation and control their reproductive functions.30. For example, the early Romans used to slip rings through the labia minora of female slaves to prevent impregnation and the crusaders of the 12th century A.D designed the Victorian chastity belts to thwart unsanctioned sex 34.
In an attempt to end the practice, the British and other colonial authorities in Africa during the 20th century criminalized the practice in several nations, with little success in reducing its prevalence53, 56.
Christian missionaries also discouraged it with mixed results57. Today an enormous variety of cultural beliefs and justification for the practice exist mostly in African countries north of the equator and the
Middle East. However in recent years, concern has been raised that immigrants from these countries are practicing this ritualistic mutilation in the United States and other Western countries such as
Canada, Australia, and New-Zealand5, 6, 9,10,37,54.
2.2 HISTORY OF TERMINOLOGY
The terminology used for this procedure has undergone various changes. During the first years in which the practice was discussed outside practicing groups, it was generally referred to as female circumcision. This term however draws a parallel with male circumcision and as a result creates confusion between these two distinct practices.
26 The expression female genital mutilation gained growing support in the late 1970s 57, 58. This terminology is used by the opponents of the practice. The word mutilation not only established clear linguistic distinction from male circumcision but it also emphasized the gravity of the act.17,53. Use of the word mutilation reinforces the idea that this practice is a violation of the human rights of girls and women and thereby helps promote national and international advocacy towards its abandonment16, 53. In 1979, WHO held the first international conference on harmful traditional practices affecting women and children in Khartoum, Sudan 57, 59. In 1990, this term was adopted at the third conference of the Inter-African Committee (IAC) on Traditional Practices affecting the health of women and children in Addis Ababa 16, 57. From the late 1990s the term female genital cutting and female genital mutilation/cutting were increasingly used, both in research and by some agencies16. The preference for this term was partly due to dissatisfaction with the negative association attached to the term mutilation and some evidence that the use of that word was estranging practicing communities and perhaps hindering the process of social change for the elimination of female genital mutilation. To capture the significance of the term mutilation at the policy level and, at the same time, to use less judgmental terminology for practicing communities, the expression female genital mutilation/cutting is used by UNICEF and UNFPA 16, 59. Also in order to avoid evoking the emotional response that some cultures invest in the practice some use the term female genital alteration60, female genital surgeries61 and female genital modification62.
In 1991, the WHO, a specialized agency of the United Nations (UN), recommended that the UN adopt the terminology of female genital mutilation and it has been used in all UN documents16.
27 2.3 WHO CLASSIFICATION
A classification of female genital mutilation was first drawn up at a technical consultation in 199516.
An agreed classification is useful for purposes such as research on the consequences of different forms of female genital mutilation, estimates of prevalence and trends in change, gynaecological examination and management of health consequences and for legal cases.
A common typology can ensure the comparability of data sets. Nevertheless, classification naturally entails simplification and hence cannot reflect the vast variation in actual practice. The WHO classification system is described below:
Type I - (sunna)- excision of the clitoral hood (prepuce) with or without partial or total clitoral
excision. Sunna means tradition in Arabic 7,10,11,14.
Type II - total clitoral excision with partial or total excision of the labia minora. This is called
Matwasat in Sudan63, 64. It is also called Khafd, meaning reduction in Arabic 17.
Type III – (infibulation, pharaonic): partial or total excision of the external genital (clitoris, labia
minora and labia majora) and stitching and /or narrowing of the vaginal opening,
Type IV – (unclassified): all other operations on the female genitalia including pricking, piercing or
incising the clitoris and/or cutting of the vagina, stretching of the clitoris and/or labia,
cauterization by burning of the clitoris and surrounding tissue; scraping of the tissue
surrounding the vaginal orifice (angurya cuts) or cutting of the vagina (Gishiri cuts);
introduction of corrosive substances and herbs into the vagina with the aim of tightening
it.
The types I and II account for up to 80% of cases while the type III accounts for 15% of
28 cases5, 7, 16. As some researchers pointed out limitations in the 1995 classification16, the WHO convened a number of consultations with technical experts and others working to end female genital mutilation to review the typology and evaluate possible alternatives. It was concluded that the available evidence was insufficient to warrant a new classification; however, the wording of the current typology was slightly modified, and subdivisions created, to capture more closely the varieties of the procedure16.
WHO MODIFIED CLASSIFICATION
Type 1a – removal of the clitoral hood or prepuce only
1b – removal of the clitoris with the prepuce
Type 11a–removal of the labia minora only
11b–partial or total removal of the clitoris and the labia minora
11c–partial or total removal of the clitoris, the labia minora and majora
Type 111a–removal and apposition of the labia minora
111b—removal and apposition of the labia majora
Type 1V – All other harmful procedures to the female genitalia for non-medical purposes.
For example, pricking, piercing, incising, scraping and cauterization.
2.4 EPIDEMIOLOGY OF FGM
2.5 PREVALENCE AND DISTRIBUTION OF FGM
It is estimated that between 100 and 140million girls and women have undergone some form of female genital cutting21, 30, 50. It is a very deeply rooted cultural and religious tradition still practiced in over
29 28 out of the 46 African countries, a few in the Middle East (such as Oman, United Arab Emirate and
Yemen) and Asian countries ( such as Indonesia and Malaysia) 30, 63. FGM is common in refugees from these areas who have settled in Europe, North America and Australia. Up to three million are at risk of this procedure annually 21-23. Nigeria, Ethiopia, Egypt, Northern Sudan, Kenya and Somalia account for 75% of all cases8, 10. The prevalence of FGM in countries where it is practiced is estimated to range from 5% in Uganda and Zaire to 98% in Djibouti and Somalia10, 30. The prevalence of FGM in Nigeria averages 50% 2, 10, 13, 30.
Types I and II are the commonest forms of FGM and generally account for up to 80-85% of mutilation practiced, although the proportion may vary greatly from country to country 2, 5, 7, 13, 16, 62, 63. Type III is the most extreme form and constitutes about 15-20% of all procedures16, 63. In some countries like Northern Sudan, Somalia and Djibouti, 80-90% of all female genital mutilation is type III8, 10, 39, 40, 65. Infibulation has been reported in Gambia, Egypt, Ethiopia,
Eritrea, Northern Kenya, some parts of Mali and Northern Nigeria 31. FGM is practiced by specific ethnic groups in Africa. For example, the kukuyi in Kenya practice it while the Luo do not66, the
Yoruba, Ibo and Hausa in Nigeria do but the Nupes and Fulanis do not. In Senegal the Fula do but the
Woloff do not. Female genital mutilation is not practiced in Southern African and Arabic-Speaking countries of North Africa except Egypt57. It is virtually unknown in Muslim countries that lie outside of Africa such as Iraq, Iran and Saudi Arabia.14. The practice is known across socio-economic classes and among various religious groups including Christians, Moslems, Jews and followers of indigenous
African religion26, 48, 53.
30 2.6 THE NATURE AND SCOPE OF FGM IN NIGERIA
Nigeria is the most populous English-speaking country in Africa. It is a multi-ethnic society with over
250 different ethnic and linguistic groups. The major tribes are Yoruba, Ibo and Hausa/Fulani. Other tribes include Ijaw, Tiv, Efik, Nupe, Ibibio, Urhobo and Bini. The main religions are Christianity and
Islam. Many Nigerians also practice traditional African religions. Islam is dominant in the North and
Christianity in the South of Nigeria.
The practice of FGM is widespread in Nigeria. The IAC (Nigeria) estimates that more than 50% of
Nigerian girls and women have undergone the operation and many more are being subjected to it yearly
2, 10.
A nationwide study of the prevalence of FGM conducted in 2001/2 showed that the practice varied widely among different groups in the Northern States of Nigeria. While the practice was as low as 5% in Taraba State, Yobe State (20%), Sokoto State (32%), it was widely practiced in Adamawa state
28 (72%), Kano State (80%), Katsina State (95%) and Kebbi state (100%) . The types commonly practiced were I and II, although types III and IV were also practiced. In the type IV FGM, “ angurya” and / or “gishiri” cuts are performed on the female external genitalia usually the vagina with the belief that it cures a wide range of ailments of the reproductive systems including amenorrheoa, menopause, dyspareunia, infertility, pruritus vulvae, vaginal stenosis and puerperal illness. Type IV FGM is commonly practiced in Southern Nigeria as the introduction of herbs into the vagina. Type II is commoner amongst Yoruba speaking people. In the Mid-Western part of the country, that is Edo and
Delta States, the prevalence was between 30-90% with types I and II being practiced. In the Eastern
States, prevalence ranges from 4-80% with types I and II being commonly practiced.
31 2.7 REASONS FOR FGM
The rationales given for the perpetuation of FGM are similar in all regions that practice it despite differences in religion, ethnicity and geography. This may however vary from community to community and from family to family. It is a manifestation of gender inequality that is deeply entrenched in social, economic and political structure and represents society’s control over women16, 67.
The critical decision makers are grandmothers, mothers, women opinion leaders, men68, age groups and the circumcisers who derive substantial economic benefits from the operation12, 27.
In the most recent NDHS of 2003, the overall prevalence of FGM in Nigeria was 19.0%16. This is in contrast with the 1999 survey35 with a prevalence of 25%. In the current survey12, 16, the prevalence of type 1 is 2%, type II is 43.5%, type III is 3.9% and type IV is 50.8%. The prevalence of FGM in
Nigeria by zone shows that it is commonest in the South-West 56.9% followed by the South- East
40.8%. Others include South-South 37.4%, North-Central 9.6%, north-east 1.3% and North West 0.4%
12 .
The reasons given by practicing communities are grouped as follows 35:
A Socio- cultural
B Hygienic and aesthetic
C Spiritual and Religious
D Psychosexual.
A. Sociocultural
32 I. Identification with the tradition/cultural heritage of the society where FGM is practiced. For example it is grave insult to refer to a woman as uncut in Sudan or to refer to a woman as having an excessively wide vaginal orifice in Somalia.
2. Initiation into womanhood/ rite of passage. This reason is given by a number of Ethnic groups in Kenya, Sierra Leone and some parts of Nigeria58. This is the case among Okpe people in Delta state and the Ibibios of Akwa Ibom.
3. Unwillingness of males to marry females with intact genitalia believing that such women are promiscuous.
B. Hygienic and aesthetic
The female external genitalia are considered dirty and unsightly and should be removed. For example, the Binis of Edo think that the clitoris causes itching (etare) or is always dirty and emits unpleasant odour10.
C. Spiritual and Religious reason
FGM is practiced by Christians, Muslims, Jews as well as practitioners of traditional African religion in a wide range of communities. It is being carried out in Muslim communities in the belief that it is a religious requirement but eminent Muslim scholars have disproved this. FGM predates Islam and there is no doctrinal basis that it is in the Koran. It is not practiced in predominantly Islamic countries like
Saudi Arabia, Iraq, the Gulf States, Kuwait, Algeria and Pakistan14. The Holy Bible makes mention of male circumcision but there is no reference at all to its female counterpart. As with the Koran and
Bible, the Torah also makes no specific mention of FGM and to date, the only Jews known to practice it are the Ethiopian Falashas, most of whom now live in Israel 53.
33 D. Psychosexual
1. The reduction or elimination of the sensitive tissues of the outer genitalia particularly the clitoris, aims at reducing sexual desires (libido) in the female and, therefore maintaining chastity and virginity before marriage and fidelity during marriage.
II. It is believed among those who practice type III FGM that the narrowness of the vaginal orifice enhances the male sexual pleasure. This is the basis of re-infibulation after childbirth.
III. To make the woman “truly feminine”. Some tribes perceive the clitoris as a potential penis which should be removed. For example, Ibo women believe that FGM makes them more feminine and thus more attractive to men 18, 52, 69.
Governments and countries are confronted with complex and culturally entrenched beliefs on FGM referred to as the mental map 38, 58.
This mental map incorporates myths, beliefs, values and codes of conduct that cause the whole community to view women’s external genitalia as a potential danger which if not eliminated has the power to negatively affect women who have not undergone FGM, their families and their communities.
These myths and superstitious beliefs help to propagate the practice of FGM. For instance, local myth holds the view that the head of the baby must not touch the clitoris else the baby will develop hydrocephalus or end up as stillbirth38. Others claim that the clitoris may swell and obstruct the delivery of the baby and that childbirth will be easier if the woman had her genitals cut. Some believe that FGM will make a woman fertile, and/or facilitate child delivery.
To make sure that people conform to the practice, communities have put strong enforcement mechanisms in place. Some of these enforcement mechanisms include rejection of women who have
34 not undergone FGM as marriage partners, immediate divorce of women not circumcised, and the use of derogatory songs. Others include public exhibitions and witnessing of complete removal before marriage, forced excisions and installation of fear of the unknown through curses and evocation of ancestral wrath38. On the other hand, girls who undergo FGM are provided with rewards, including public recognition and celebrations, gifts potential for marriage, respect and the ability to participate in and with social functions.
Culture is defined as the body of learned beliefs, customs, traditions, values, preferences and codes of behaviour commonly shared among members of a particular community.
Traditions are the customs, beliefs and values of a community, which govern and influence members’ behaviour. Traditions constitute learned habits, which are passed on from generation to generation and which form part of the identity of a particular community. People adhere to these patterns of behaviour, believing that they are the right things to do. Traditions are often guarded by taboos and are not easy to change.
The people who practice FGM share a similar mental map 38, 58 that presents compelling reasons why the clitoris and other external genitalia should be removed.
35
Figure 2.238,58 :
As shown in figure 2.238,58, all the reasons fit into an elaborate belief system that operates on different levels- all targeting the external genitalia of women and girls.
The three overlapping reasons for the practice at the centre of figure 2.2 - spiritual and religious reasons, sociological reasons and hygienic and aesthetic reasons- seem to indoctrinate society into the practice without explicitly addressing women’s sexuality.
36 According to these reasons, the clitoris and external genitalia are believed to be ugly and dirty, and if not excised can grow to unsightly proportions. In addition, they are purported to make women spiritually unclean. Their removal is thus required by religion. The clitoris is also believed to prevent women from reaching maturity and having the right to identify with a person’s age group, the ancestors and the human race. According to the numerous myths associated with this set of beliefs, the external genitalia have the power to make a birth attendant blind, cause infants to become abnormal, insane or die, or cause husbands’ and fathers’ death38.
Once people are educated about the reasons for FGM, a larger more encompassing psychosexual reasons emerge that directly focus on the sexuality aspects of the external genitalia and the dangers that may befall the girl, her family, potential husbands, and society in general if these parts of the external genitalia are not eliminated. From this perspective, a young woman’s sexuality has to be controlled to ensure that she does not become over-sexed and lose her virginity, thereby disgracing her family and losing her chance of marriage. In fact, it is believed that because an uncut clitoris will become big, activities like riding a bike or a horse, or even wearing tight clothing will arouse a woman in whom it is not excised, who may even rape men. It is believed that such a woman is likely to be promiscuous and therefore cannot be trusted by potential suitors.
At the community and at the family level, strong pressure is brought to bear on women and girls to ensure continuation of the practice of FGM. Women in whom it is not excised face immediate divorce or forcible excision. As initiates, girls are sworn into secrecy so that the pain and ordeals associated with the procedure of FGM will not be discussed, especially with women in whom it is not excised.
37 Songs and poems are used to deride girls whose are not excised. The fear of the unknown through punishment by God, ancestral curses and other supernatural powers is instilled in them.
ATTITUDES TOWARDS FGM
Almroth and Almroth-Berggren70 in their noted study that the majority of men and women in the Sudan were in favour of discontinuation of FGM. They also showed that those who were against the practice were younger and more educated, suggesting that the younger ones were initiating a change of attitude.
In Somalia where FGM is almost universal, it is the older women who are more interested in perpetuating the practice.
AGE OF "CIRCUMCISION"
The age at which "circumcision" is performed varies from one ethnic group to another3. Most commonly it is done between 4-10 years of age, a time when they can be made aware of the social role expected of them as women 22, 25, 26, 31-33,35. It is performed in some communities during infancy in the first eight days of life as is the case amongst the Owu people in Abeoukuta, Yorubas of Ibadan, the Ibo in the East, and some Muslims in some parts of the North and the Amhara in Ethiopia. Roughly 79% of circumcised women in Nigeria have the procedure in infancy 18. In Egypt and many tribes in Central
Africa it is carried out in childhood. In some Edo communities of Nigeria, it is performed at approximately the age of 10 years as practiced in Somalia and the Gava tribe in Chad 10, 13.
Female genital mutilation is also performed much later in life between 13-18 years when the girl is of marriageable age, during the first pregnancy or prior to delivery at term. This is the case in Okpe community in Delta State and among the Ibibio in Akwa Ibom. The Ijaws also perform FGM after the
38 death of a woman in whom the rite had not been done before she is allowed to be buried. In those cultures, crying is prohibited until the corpse is mutilated and ceremonies performed10,12.
THE PRACTITIONERS OF FGM
The practitioners can be classified into two broad subgroups – The traditional and formally trained health workers. Among the former are the traditional healers, birth attendants, Hausa barbers while the latter are nurses and medical doctors.
The occupation in Nigerian culture is limited to only people belonging to certain families10,12 and the skill is passed down from one generation to the other. Yoruba circumcisers are referred to as Oloola, while the Ngozoma and the Wanzami perform the operation in many parts of the Northern States of the Country9, 10. In many other societies, old women with powerful positions who are highly respected carry out the procedure. In Somalia these old women of the village are known as Gedda. The operation is done by TBAs known as Daya in Egypt and Sudan11, 71. These operators are highly respected women leaders who control traditional secret societies. All these people are greatly respected and paid for their services in cash and kind. In Nigeria, circumcisers are compensated in cash or in kind with payments ranging from 300 – 500 Naira; higher amounts are paid in Yoruba-speaking regions 10.
In urban areas and among the affluent, the procedure is becoming increasingly performed in health facilities by qualified health personnel such as nurses, midwives and doctors on the assumption that it is better to perform it in a hygienic environment to avoid infections, to control pain and to encourage the less drastic forms of cutting as a first step towards its eradication 16, 35. Since 1982, the WHO has strongly condemned this “medicalization” and has unequivocally advised that FGM must neither be
39 institutionalized nor should health professionals in any setting, including hospitals or other health establishments perform any form of FGM58.
THE PROCEDURE
In some settings, genital mutilation is performed when the subjects are quite young and uninformed and is often preceded by acts of deception, intimidation, coercion and violence by trusted parents, relatives and friends. For many girls genital mutilation is a major experience of fear, submission, inhibition, and suppression of feelings and thinking. This experience becomes a vivid landmark in their mental development, the memory of which persists throughout life 35, 49.
The operation usually lasts for 10-20 minutes and generally no anaesthetics, antiseptics, analgesics or antibiotics are used 14, 27, 34. The child is held down by three or four women while the operation is performed 38. There is often unintended additional damage done to these girls due to crude tools, poor light, and poor vision of the practitioner, septic condition and the struggles of the girl/woman during the procedure7, 31,58.
The technique employed in each type is described as follows: In the type I, which is the commonest form, the clitoris is held between the thumb and index finger, pulled out and amputated with one stroke of a sharp object. The wound is dressed by applying mixtures of native herbs, earth, cow dung, ash etc depending on the excisor and the prevailing culture. Bleeding is usually stopped by rubbing the wound with these concoctions and applying gauze and a pressure bandage. Modern trained practitioners may insert one or two stitches around the clitoral artery to arrest the bleeding 32, 33. In the type II variety, the clitoris is amputated as described above and the labia minora are partially or totally removed, often
40 with the same stroke. In the type III variety, the amount of tissue removed is extensive. It involves the complete removal of the clitoris and labia minora, together with at least two-thirds, and often the whole of the medial part of the labia majora. The raw edges of the labia majora are then stitched together with silk, poultices or thorns to hold them in place and the girl’s legs are then firmly tied together from above the knee to the ankle to discourage movement for 2-6 weeks until the wound is healed. If she dies from complication, the excisor is not held responsible rather the death is attributed to evil spirits or fate35. The healed scar creates a hood of skin which covers the urethra and part or most of the vagina and which acts as a physical barrier to intercourse. A tiny opening is left at the bottom of the incision to allow the exit of urine and menstrual flow. The opening is surrounded by skin and scar tissue and is usually 2-3cm in diameter but may be as small as the head of a matchstick31-33.
If after infibulation the posterior opening is large enough, sexual intercourse can take place after gradual dilatation, which may take days, weeks, months or, in some cases as long as two years31. If the opening is too small to start the dilatation, re-cutting (defibulation) before intercourse is traditionally undertaken by the husband or one of his female relatives using a sharp knife or a piece of glass. Modern couples may seek the assistance of a trained health professional, although this is done secretly, possibly because it might undermine the social image of the man’s virility.
In almost all cases of infibulation, defibulation must also be performed during childbirth to allow exit of the fetal head with tearing of the surrounding tissue. If no experienced birth attendant is available to perform defibulation, fetal and / or maternal complications may occur because of obstructed labour35,72.
Traditionally, re-infibulation is performed after the woman gives birth. The raw edges are stitched together again to create a small posterior opening, often the same size as that which existed before
41 marriage. This is done to create the illusion of virginity, since a tight vagina is culturally perceived as more pleasurable to the man. Owing to the extensive nature of both the initial and repeated cutting and suturing, the physical, sexual and psychological effects of infibulation are greater and longer-lasting than for other types of FGM31. The type IV FGM encompasses a variety of procedures. The common ones are Angurya cuts which describe the scrapping of the tissue around the vaginal opening and
Gishiri cuts which are cuts from the anterior vaginal wall in an attempt to widen the vaginal outlet to relieve obstructed labour. They often result in vesico-vaginal fistulae and damage to the anal sphincter.
2.8 HEALTH CONSEQUENCES OF FGM
The health complications of FGM have been described as the three feminine sorrows: sorrows on the day FGM takes place, the night of the wedding when often the woman has to be cut prior to intercourse and when the woman gives birth and the vaginal opening is not large enough for a safe delivery 19, 69
. The complications of FGM may be physical or psychosexual. Various studies have documented the short and long-term physical complications7, 41 but little has been done on the psychosexual effects on girls and women who have undergone FGM 11, 22, 39, 53.
The physical complications are common to all types of mutilation but are worse with the infibulations71, 73, 74.
Immediate physical complications include:
(1) Severe pain – This may lead to shock and death. It is due to the rich nerve supply of the clitoral region as the majority of FGM are done without anaesthetics. Those performing it on infants do so believing they are not capable of feeling much pain. When local anaesthesia is used, pain in the highly
42 sensitive area of the clitoris returns within 2-3hours of the operation. Applying the local anaesthsia is itself extremely painful because the area of the clitoris and labia minora has a dense concentration of nerves and is highly sensitive. The use of general anaesthesia adds to the risk of death since it is usually not given by a specialist with paediatric experience. A 12- year old Egyptian girl Badour Shaker died from an overdose of anaesthesia in June 2007 soon after a circumcision17, 53.
(2). Haemorrhage – Is the most common and life threatening complication of FGM. It is almost unavoidable as amputation of the clitoris involves cutting across the high-pressure clitoral artery34. The degree of haemorrhage also depends on the proficiency of the operator, the bluntness of the instruments used and the struggles of the girl or woman because of pain and fear7, 8, 31. Severe acute bleeding can lead to haemorrhagic shock and death while protracted bleeding may result in severe anaemia which interferes with growth in children and women who probably are already malnourished.
(3). Infection- this is very common due to unhygienic conditions and the use of unsterilized equipment.
Herbs ashes and other substances applied to the wound for healing provide excellent growth medium for bacteria. Binding the legs together after infibulation interferes with drainage of the wound and may lead to ascending infection, which may cause chronic pelvic infections and infertility. Infections can also result in ulcers, abscess, ascending urinary tract infection, tetanus, gangrene and septicaemia.
Group cuttings in which the same non-sterile instrument is used may increase the risk of blood-borne infections such hepatitis B and HIV16,39,50,75,76.
(4) Acute urinary retention– This is very common. It may last for a few hours or days and is due to fear, pain, oedema or damage to the urethra.
43 (5) Injury to adjacent tissues- This could involve the vagina, urethra, rectum or perineum. Such may lead to incontinence
(6) Fracture or Dislocation- Fracture of the clavicle, femur or humerus, or dislocation of the hip joint can occur if heavy pressure is applied on the struggling child8, 20, 37.
(7) Shock- This may develop immediately due to excruciating pain (neurogenic) or due to acute severe blood loss (haemorrhagic).
(8). Death- This can result from severe bleeding (haemorrhagic shock), from pain and trauma
(neurogenic shock) or from sever and overwhelming infection (septicaemia)
The long-term physical complications include:
(1) Dermoid cyst- This is the most common long-term complication of FGM. It results from the embedding of epithelial tissue in the scar during healing. The sebaceous gland which normally lubricates the skin continues to secrete under the scar and form a cyst or sac full of cheesy material.
The size of dermoid cyst varies and may be as large as an orange or the head of a fetus.14, 22. Although not a serious threat to physical health, these cysts are extremely distressful and may prevent sexual intercourse and walking74, Small dermoid cysts should be left alone to avoid further damage to the area, and the woman reassured. If cysts become very large or infected, surgical removal may be unavoidable.
(2) keloid formation - This is due to genetic susceptibility 39 . They shrink the genital orifice considerably 20, 28 and some have been known to become as large as to obstruct walking 8. Vulval keloids are disfiguring and psychologically distressing. Treatment is often unsuccessful since surgical removal frequently provokes further growth. keloids together with dermoid cysts cause much anxiety,
44 shame and fear as such women think their genitalia are regrowing in monstrous shapes or fear they may have cancer.
(3)- Clitoral neuroma- This can develop when the dorsal nerve of the clitoris is cut or trapped in a stitch or scar tissue of the healed wound 31, 77 and the whole genital area becomes permanently and unbearably painful and hypersensitive with associated dyspareunia or pain during washing8.
(4)- Labial adhesions. These are commonly seen with type III mutilation. They take the form of bridges across the introitus between the two labia.
(5) Vulval abscesses. These occur due to infected cysts or other deep infection resulting from faulty healing or an embedded stitch that fails to be absorbed31.
(6) Dyspareunia. Sexual intercourse can become painful and psychologically distressing as a result of one or several of the other complications 27, 31. Scarring and reduction in the vaginal opening may make vaginal penetration difficult or even impossible and re-cutting may be necessary.
(7) Recurrent urinary tract infection. Ascending infection from the urethra or stasis of urine can spread to the ureters and kidneys. If not treated promptly or adequately, this can become recurrent or result in bladder or kidney stones, and may ultimately lead to kidney damage8, 39.
(8) Calculus formation – Stones may develop in the vagina as a result of accumulation of menstrual debris and urinary deposits78, 79.
(9) Reproductive tract infections- These result in chronic pelvic pain and infertility. Ascending infections from the vulva due to retained discharge and blood can lead to pelvic inflammatory disease8 which is not only painful but can lead to infertility as a result of scarring of the fallopian tubes.
45 (10) Menstrual difficulties- Dysmenorrhea (painful menstruation) may occur due to increased pelvic congestion resulting from infection. Haematocolpos often occur as a result of partial or total vaginal occlusion and may cause abdominal distension.
(11) Problems in labour and delivery. These are very common following type III mutilation, especially when the girl marries at a young age as is often the case in regions where FGM is most common. The tough scar tissue that is formed occludes, to varying degrees, the vaginal opening, blocking the passage of the fetus during delivery. This can cause prolonged and obstructed labour, perineal lacerations; postpartum haemorrhage, wound infection, uterine rupture or prolapse, neonatal harm (including fetal distress, brain damage or stillbirth) and maternal death. Infibulated women must be defibulated
(anterior episiotomy) to allow passage of the fetal head from the vagina and where midwives and doctors are not familiar with such procedures, caesarian sections may be performed. FGM may contribute to maternal mortality and morbidity through increased risk of bleeding or infection. A WHO study group on female genital mutilation and obstetric outcome showed that women with FGM are significantly more likely than those without FGM to have adverse obstetric outcome and risks seem to be greater with more extensive forms of mutilation1, 12, 16, 17, 22.
(12) Difficulties in providing gynaecological care. Scaring from type III mutilation may reduce the vaginal opening such that insertion of a speculum for cervical smear or IUCD may be impossible.
The relationship between FGM and its health consequences is not understood by many women, particularly the long-term complications affecting sexual intercourse and childbirth which may occur several years after the procedure. In many cultures, women have become socially conditioned to accept the practice and the pain it causes. The traditional practitioners however are often aware of the health
46 problems and make up various myths to make women believe that these problems are the norm. Some of these physical complications have been documented both within and outside Nigeria.
In a study by Mandara9 to determine the prevalence and distribution of female genital mutilation procedures amongst 500 consecutive women at the Obstetrics and Gynaecologic unit of the Ahmadu
Bello University, ‘Zaria’; of the 170 that had FGM, giving a prevalence of 34%, 23 reported complications. Nine had excessive bleeding, seven had difficult urination, four had collapse and three had VVF from gishiri cut. The result suggested that educational attainment had the most influence on the decision as whether or not a woman would have FGM performed on her daughters
Onuh et. al.2 in a descriptive cross sectional study of 182 respondents who were nurses in Benin City,
Edo State and Eku in Delta State found a prevalence rate of 44%.
Nkwo and Onah79 in Enugu Nigeria carried out a prospective observational study of 1000 consecutive
Ibo females with a mean age of 33.4±3.5 years. Of the 1000 women examined, 354 were circumcised giving an overall circumcision rate of 35.4%. This prevalence was lower than 68% recorded in a previous study 20 years earlier in the same institution. They concluded that FGM is a dying practice amongst the Nigerian Ibos.
Snow et. al.65 in Benin conducted a cross sectional study on 1709 women aged 15-49years to determine the prevalence, social determinants and validity of self-reporting for FGM. The prevalence was highest among the Bini and Urhobo, among those with the least education, and particularly high among adherents to Pentecostal churches. There was a steady and steep secular decline in the prevalence with age –specific prevalence rates of 75.4% among women aged 45-49 years, 48.6% among 30-34 years old and 14.5% among girls aged 15-19.
47 In a cross-sectional study of 210 antenatal patients seen at Amino Kano Hospital by Abubakar et. al. 45, the prevalence of circumcision was 23.3%.
Okonofua et. al.81 in Benin using 1636 healthy pre-menopausal women in a cross-sectional study had a prevalence rate of 45%. Female genital cutting in this group of women did not attenuate sexual feelings. However FGM predispose women to adverse sexuality outcomes including early pregnancy and reproductive tract infection. Cut women were up to 2.8 times more likely to have reproductive tract infection. Therefore FGM cannot be justified by arguments that it reduces sexual activity in women and prevents adverse outcomes of sexuality. A clear outcome of this analysis was that the decline in female circumcision was in place before the turning point of the global movement for its eradication.
In a study by Adeokun et. al. 18 to find out changes in female circumcision occurring in two
Southwestern States of Nigeria between 1933-2003 in a cross-sectional study using cohort analysis of
1174 female live births to 413 women, the prevalence of circumcision was 52.4%.
In a cross-sectional study of 600 respondents in Port-Harcourt utilizing structured questionnaire by
Ugboma et. al.29, the prevalence of FGM was 53.2%. Medical doctors were the most mentioned operators (34.5%)
Obi in Abakiliki, Ebonyi State82 evaluated 800 consecutive pregnant women in a cross-sectional study and got a prevalence rate of 35%. The prevalence decreased with the woman’s age and women whose parents belonged to a lower social class were more likely to be circumcised.
48 3 Ekenze et. al. carried out a prospective evaluation of girls with genital complications of FGC at the
Federal Medical Centre Owerri, south - east Nigeria. Of the 21 patients, clitoral swelling and labial fusion was present in 13 (61.9%) and 8 (38.1%) respectively
In a questionnaire-based face-to-face interview conducted on 610 pregnant Igbo women attending the antenatal clinic of Nnamdi Azikiwe University Teaching Hospital and summit Specialist Hospital both in Nnewi in Anambra State by Adinma and Agbai44 , genital mutilation occurred in 296(48.5%). Their study showed that the incidence of FGM was lowest among women of 16-20 years age group and highest among the 36-40 years age group. It was also highest among grandmultiparous women (para five and above) and women of social class 5. Eighty (13.1%) of the women still advocate FGM of their daughters
In the study carried out by Igwegbe and Egbuonu on 325 consecutive live female deliveries at Nnamdi
Azikiwe University Teaching Hospital83, there was no genital mutilation observed among the 200 female babies whose mothers completed the 9 months follow up. The prevalence of FGM among the mothers was 48%
Dare et. al.4carried out a cross-sectional survey of all women who presented in labour at the Obafemi
Awolowo University teaching Hospital, Lautech Teaching Hospital Osogbo and Ogun State University
Teaching Hospital Sagamu. Of the 522 circumcised respondents, up to 67% reported having had complications following circumcision. The types of FGM encountered were types I and II. A total of
127 women (19%) wanted their female children to undergo the procedure. This calls for a behaviour- change approach for the eradication of FGM
49 A study conducted on 430 consecutive pregnant women attending the antenatal clinic of Wesley Guild
Hospital Obstetric Unit by Ogunlol et. al. 84 revealed that 60% of the women had a type of genital mutilation. Seventy-four (17.2%) of the women and 146 (34%) of their husbands would circumcise their female child. Therefore every effort should be taken to involve men in the struggle to eradicate this unwholesome practice
Adekunle et. al.75 studied the vulval complications of female genital mutilation in 39 patients managed at the University College Hospital, Ibadan over a 10 year period. The complications were: labial adhesions (51.3%) and clitoral retention cyst (48.3%)
Feyi- Waboso and Akinbiyi 13 conducted a study on 600 consecutive pregnant women attending antenatal clinic at Abia State University Teaching Hospital. The prevalence was 60.4% and the most common type (62.7%) was clitoridectomy. Only 19.8% of respondents wanted the practice to continue and would like their daughters to be circumcised in the future. Most of the respondents (53.4%) were circumcised shortly after birth and most procedures were performed by elderly women (57.1%).
In a cross-sectional study among the Hausa community in Sabo, Sagamu by Oduwole and Iyaniwura
28, a total of 245 respondents (177 female and 68 males) were involved. The prevalence was 69.9% among the female respondents. 98(79.9%) had type I and 0.8% had type II FGM. 93% were circumcised in the first week of life. Traditional birth attendants (68.3%) and barber surgeons (27.6%) circumcised the majority of them at home using a small knife commonly called Aska.
In a hospital- based cross sectional study in Benin, Edo State Slanger et. al. 85 used self-reporting of
1709 women via questionnaire to examine the association between FGM and a number of aspects of both reproductive and sexual health on first delivery. The interview was followed by a clinical exam
50 to determine the presence and extent of genital cutting. Their study showed a prevalence of 56%. 72% of the respondents had type I cutting, 24% type II and 4% type III and IV. Although univariate analysis suggested an association between genital cutting and delivery complications( haemorrhage and perineal tear) and procedures( episiotomy, caesarian section and instrumental delivery), multivariate analysis controlling for socio-demographic factors and delivery setting showed no difference between cut and non cut women’s likelihood of reporting first-delivery complications or procedures.
Larsen and Okonofua 86 in a cross sectional health survey interviewed and examined 1861 women aged
15-49 in Benin. 45% were circumcised based on medical exam; 71% had type I and 24% had type II.
Circumcised women experienced more obstetric complications.
Nwajei et. al.87 in a cross sectional study of 400 female university students in Abraka examined the effects of female circumcision on their sexuality. 70% of the respondents were not circumcised. This implied that as more people become educated, female circumcision may die a natural death. The study also found that the students who were circumcised favoured circumcision more than those who were not. Other findings included the shift of sensitivity from the clitoris to other parts of the body amongst the circumcised, the uncircumcised woman being more likely to initiate sexual intercourse than the circumcised; the uncircumcised women have increased frequency of intercourse than the circumcised.
It was recommended that campaigning against female genital mutilation should be waged against those women who are already circumcised and women with low level of education
Morrison et. al. 88 conducted a cross sectional community survey of 1348 women aged 15-54 years in
Gambia to estimate the prevalence of reproductive morbidity on the basis of women’s reports, a gynaecological examination and laboratory analysis of specimens. Descriptive statistics and logistic
51 regression were used to compare the prevalence of morbidity between cut and uncut women adjusting for possible confounders. 58% had signs of genital cutting. The majority of operations consisted of clitoridectomies and was performed between 4 and 7 years. Women who had undergone FGM had a significantly higher prevalence of bacterial vaginosis (BV) [adjusted odds ratio (OR) – 1.66; 95% confidence interval (CI) 1.25 – 2.18] and a substantially higher prevalence of herpes simplex virus 2
(HSV 2) [adjusted OR – 4.71; 95% CI 3.46 – 6.42].
Jones et. al. 40 carried out two clinic based studies from Mali and Burkina Faso using 5337 and 1920 women on the health effects of FGM and their negative health outcomes. In Mali 94 % had been cut whereas in Burkina Faso 93% had been cut. More rural than urban women were cut (98% and 93% respectively, p< 001). Whereas type II was the most frequently performed in Mali, type I was the most common practice in Burkina Faso. Infibulation or type III cutting was found in 5% of both samples.
The most frequently noted complication differed for each sample (keloid in Burkina Faso and
Haemorrhage in Mali. A possible explanation was that type I cutting was more prevalent in Burkina
Faso and that the formation of a keloid scar was the most observable complication among women who had undergone clitoridectomy. In Mali where the more severe type II cutting was most prevalent, women had more genital tissue removed and therefore haemorrhage from the scar tissue occurred more often. There was clear association between delivery complication and circumcision. Moreover the likelihood of experiencing a difficulty during delivery increased with the severity of cutting. Five percent of women without a cut experienced a delivery compared with 18% of women who had type I cutting. 30% of women with type II cutting and 35% of women with type III cutting. Those with types
II and III were significantly more likely to suffer a perineal tear during delivery
52 Gage and Van Rossem 41 in Guinea investigated the socioeconomic correlates of and gender differences in attitudinal support for the discontinuation of FGM. Data was collected from structured interview of 1851 men aged 15-59 and 6364 women aged 15-49 in the 1999 demographic and health survey. More than 9 out of 10 women had undergone FGM. Attitudinal support for discontinuation was more prevalent among men than women. The odds for supporting the discontinuation of FGM were negatively related to beliefs in social approval of and religious support for FGM and its enhancement of women’s marriageability, the number of perceived advantages of FGM and women’s socioeconomic status.
Satti et. al.89 recruited 255 girls aged 4-9years in Sudan in a paediatric emergency ward to estimate the prevalence of FGM, identify the types performed and associated social factors. Twenty percent of the study group had undergone FGM and 50% of guardians indicated that it would be done. In 66% of those who had undergone the procedure, it was WHO type III. All operations had been performed by health professionals, mainly midwives. Those who had or intended to allow their daughters to undergo
FGM are of significantly lower socio-economic status (p=0.0008) and lower education status of parents
(mothers, p= 0.0015, and fathers, p=0.0266).
Klouman et. al.15 carried out a community- based cross sectional study of 1993 eligible female population aged 15-44 years in a rural ethnic village in Tanzania to determine the prevalence and type of FGC, its associated demographic factors, its possible association with HIV, sexually transmitted infections (STIs) and infertility and to assess the consistency between self reported and clinically observed FGC. The prevalence was 72.5% with type I as 44.9%, type II 53.1% and type III was 2.0%.
FGC was not associated with HIV, other STIs and infertility. A positive, non-significant association
53 between FGC and bacterial vaginosis was found. There was a significant decline of FGC over the last generation. An inconsistency between self-reported and clinically determined FGC status was observed in more than one-fifth of the women.
Msuya et. al.50 interviewed and examined 379 urban women of reproductive age in Kilimanjaro,
Tanzania, to determine prevalence, type, social correlates and attitudes towards FGC and to examine the association of FGC and gynaecological problems reproductive tract infection(RTIs) and HIV. The prevalence was 16.6%. Type I was the commonest in 97% of cases type II was 3% and there was no type III. Twenty four percent of the cut women intended to cut their daughters. Young age was positively associated with the intention not to continue with the practice. Keloid formation was the most observed gynaecological complication. HIV and hepatitis B infection were not associated with genital cutting.
Elmusharaf et. al. 52did a hospital based case control study on the association between female genital mutilation and sexually transmitted disease in Sudan using 222 women aged 17-35 years. Women recruited for the study were divided into cases with seropositivity for Neisseria gonorrhoea,
(gonococcal antibody test), Chlamydia trachomatis(enzyme immunoassay) or Treponnema pallidum
(Treponnema pallidum haemaglutination assay) (n=26) and controls without antibodies to these species. Socio-demographic data was obtained and genital examination done to classify the form of
FGM. Cases and controls were compared using logistic regression to adjust for covariates. Of the cases
85% had undergone the most severe forms of FGM compared with 78% of controls. There was no association between serological evidence of STIs and extent of FGM
54 Islam and Uddin 64 in a survey of 1000 randomly selected women determined the prevalence, the social and demographic correlates, women’s attitude toward the practice and their perception of their husband’s attitudes. More highly educated and economically better off women were less likely to be supportive of the practice. Based on the women’s perceptions, men were more likely than women to favour discontinuation.
Elmusharaf et. al.63 in a cross sectional study of 255 girls aged 4-9 years and 282 women aged 17-35 years, assessed the reliability of self reported forms of genital mutilation and to compare extent of cutting verified by clinical examination with the corresponding WHO classification. The reliability of self reported form of FGM was low. There was considerable under reporting of the extent. The WHO classification failed to relate the defined forms with the extent of the operation.
Almroth et. al.90 carried out a community based study in Sudan to investigate the practice of FGM among 120 young and old parents (30 young women, 30 grandmothers, 30 young men and 30 grand fathers). They were randomly selected for interview using structured questionnaire. All female respondents had undergone FGM. All grand parents had let their first daughter undergo FGM but 50% of young women and 38% of young men had decided not to let their first daughter undergo FGM.
There was a significant shift in practice from infibulation to clitoridectomy between generations.
Rahlenbeck and Mokennen69 interviewed 1942 women aged 15-49years on female genital cutting in
Ethiopia. Rates showed a secular decline, decreasing from 77% in women aged 45-49years old to 59% in those aged 15-24. Maternal education was a strong predictor of having a circumcised daughter. In logistic regression controlling for covariates, education and self empowerment were factors associated with rejecting FGM.
55 Almroth et. al. 70 explored the paediatric complications of female genital mutilation in a hospital based study in Khartoum, Sudan. 255 consecutive girls aged 4-9years presenting to an emergency ward were included in the study. Full examination including inspection of genitalia, was performed. Dipsticks for nitrite and leucocytes were used to diagnose suspected urinary tract infection. Fifty two girls (20%) had undergone FGM. Out of the 48 girls with FGM on whom it as possible to inspect genitalia to verify the form of FGM, 13(27%) had WHO type I, 3(6.3%) had WHO type II and 32 (66.7%) had type III. Among girls below the age of 7 years, there was a significant association between FGM and UTI.
El-Defrawi et. al.92 in Egypt randomly selected 250 women in Egypt who were examined gynaecologically and had semi structured interview based on sexual behaviour assessment schedule –
A. The aim was to investigate the psychosexual impact of female genital mutilation. The results showed that the 80% of them who were circumcised complained more significantly of dysmenorrhea
(p<0.001), and dryness during sexual intercourse (p<0.05) than the uncircumcised women.
Significantly, more of the circumcised women reported lack of sexual desire (83%, p<0.01), less enjoyment of sex (p<0.001), less initiation of sexual activity with husband (p< 0.05), being less orgasmic (p<0.001). The groups did not differ regarding dyspareunia and foreplay (p>0.05). The study suggested that circumcision had a negative impact on a woman’s psychosexual life.
Similarly, Elnashar and Abdelhady93 randomly selected 264 newly married women in Egypt to determine the prevalence and to make a comparison between circumcised and uncircumcised women regarding long-term health problems. Circumcised group constituted 75.8% of the sample. All noncircumcised women were living in the urban area. Dysmenorrhea was more common among
56 circumcised than uncircumcised (p<0.01). Marital problems (dyspareunia, loss of libido, failure of orgasm and husband’s unsatisfaction) had statistical significance among circumcised women. Obstetric problems such as tears, episiotomy, and consequently distressed babies were more events among the circumcised women with statistical significance. Circumcised women had significant mental problems such as somatization, anxiety and phobia (p<0.001).
Banks et. al. 1 in a WHO collaborative study examined 28,393 women attending for singleton delivery in six African countries including Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan. They were examined before delivery and followed up until discharge from hospital. Compared with women without FGM, the adjusted relative risks of certain obstetric complications were, in women with FGM
I, II and III respectively: caesarian 1.03(95% CI 0.88-1.21), 1.29(1.09-1.52), 1.31(1.01-1.70): postpartum haemorrhage 1.03 (0.87-1.21), 1.21 (1.01-1.43), 1.69 (1.34-2.12): extended maternal hospital stay 1.15(0.97-1.35),1.51(1.29-1.76), 1.98(1.54-2.54); infant resuscitation 1.11(0.95-
1.28),1.28(1.10-1.49),1.66(1.31-2.10) stillbirth or early neonatal death 1.15(0.95-1.41), 1.32(1.08-
1.62),1.55(1.12-2.16).
Wuest et. al.94 did a retrospective case- control study in Switzerland on 122 women with FGM and
110 controls matched for maternal age. All the mutilated women were immigrants from Somalia
(n=42), Sudan (n=33), Ethiopia (n=27), Tanzania (n=3), Kenya (n=6), Egypt (n=4) and Far East (n=7).
A type I FGM was present in 21 patients, Type II in 29; Type III in 58 and 14 patients had Type IV.
Majority of the patients had undergone infibulations. There were no differences for FGM patients and controls regarding fetal outcome, maternal blood loss or duration of delivery. FGM patients had significantly more often an emergency caesarian section (p=0.0012) and third degree vaginal tears than
57 the controls. A weakness of this study is that FGM patients and controls were only matched for age and not for parity, ethnicity, etc, which may influence results.
Catania et. al. 95 in Italy investigated 247 women in four groups (A=137 adult mutilated women, B=58 young, unmarried and mutilated ladies, C=15 defibulated women and D= 57 infibulated women). A semi-structured interview was employed on groups A, B and C, whereas group D was investigated with the Female Sexual Function Index (FSFI) questionnaire which has six domains namely: Desire, arousal, lubrication, orgasm, satisfaction and pain. Group D had a similar control group of 57 unmutilated women. Their result suggested that FGM does not have a negative impact on psychosexual life in all the groups. There was a significant difference between study and control group in desire, arousal, orgasm and satisfaction with mean scores higher in the study group. No significant differences were observed between the two groups in lubrication and pain. They suggested that the study should be replicated on a larger and random sample.
Livermore et. al.66 used questionnaire to interview 68 subjects in Kenya. There was a prevalence of
43%. The prevalence had changed over three generations: the interviewees, their mothers and their children. The decrease in prevalence was statistically significant (p<0.01). Their sample was too small.
Behrendt and Moritz 26 assessed the psychological impact of FGM in 23 circumcised Senegalese women. Twenty-four uncircumcised Senegalese women served as control. The circumcised women showed a significantly higher prevalence of Post traumatic stress disorder than the uncircumcised women.
PSYCHOSOCIAL COMPLICATIONS
58 Not much information exists on the psychosocial consequences of FGM 8, 11, 22, 25,26,31,37, 41, 53, but it is believed that the agony endured during the operation can have a lifetime effect on the minds of these women5, 8, 14 31, 49.
Psychologically, even before the operation in older children, the threat of cutting and the fear- provoking situation is believed to be capable of disturbing the mental state of the child such that it causes worry, nightmares and panic35. The fear and trauma of the operation coexists with the desire to gain social status, comply with peer pressure and please the family. But if complications occur, the psychological trauma is usually severe leading to a syndrome of genitally focused anxiety and depression31, 34, 39 characterized by constant worry over the state of their genitals, intolerable dysmenorrhea and fear of infertility. The psychological problems include chronic anxiety, depression, feelings of fear, humiliation, and betrayal, and stress, loss of self-esteem, phobias, and panic attacks 31,
32. These may manifest as psychosomatic symptoms such as nightmares, sleeping and eating disorders, disturbances of mood and condition, loss of appetite, excessive weight loss or gain and negative body image27, 34 These problems may be submerged in the child’s sub consciousness and could trigger off behavioural problems later on in life. In the long term, women may suffer feelings of incompleteness and indifference to sex 5.
2.9 THE LEGAL STATUS OF FGM
As far back as the early 1950s, the UN had identified with the issue of FGM through its human rights commission and the Economic and Social Council. In the 60s and 70s much publicity was given to the crusade against female genital cutting by feminists and women’s organizations.
59
In 1979, a WHO seminar on traditional practices57, 59 affecting the health of women and children was held in Khartoum, Sudan and all the participants resolved that the practice in all its forms be abolished.
In 1980 at the World conference of the UN Decade for women in Copenhagen, an appeal was made to all African governments and women organizations to seek solutions to the problem of FGM. In that same year, WHO and UNICEF jointly declared that they would involve national governments in the fight to abolish FGM, that they should integrate the fight against the practice into their Primary Health
Care Programmes
In 1994, a seminar on traditional practices affecting the health of women and children was held in
Dakar, Senegal26. Here an Inter-African Committee (IAC) on traditional practices affecting the health of women and children was set up. The IAC now has national committees in 28 countries and it is chiefly the efforts of this group that has led to the adoption of the term ‘Female Genital Mutilation’
The IAC has spearheaded anti-FGM efforts trough regional conferences, advocacy and research at national, regional and community levels all over Africa
The 1990s have seen growing pressures against the practice from women groups, human right organizations, child welfare groups and professional organizations26.
In 1994, an international conference on population and development (ICPD) was held in Cairo, Egypt.
Its program of action included recommendations committing governments and communities to take urgent steps to stop FGM. The platform for action of the 2nd World conference on Women at Beijing
China in 1995 also urged national governments and NGOs and international organizations to develop policies and programmes to eliminate all forms of discrimination against the girl child including FGM.
60 Continued advocacy by women groups have placed FGM on the agenda of governments and regional and international organizations. UNICEF, UNFPA, WHO and FIGO have openly condemned the practice26.
Many Heads of states including those of Benin Republic, Burkina Faso, Egypt and Senegal have at one time or the other spoken out publicly against the practice. Some countries have issued official statements or developed policies against FGM 22, 30. Although laws alone will not end FGM, they demonstrate critical governmental commitment and can create an avenue for legal action 30. There are now specific laws which explicitly prohibit FGM in Benin (2003), Burkina Faso (1996), Central
African Republic, Chad (2003), Cote d’Ivoire (1998), Djibouti (1994), Ghana (1994), Guinea, Kenya
(2001), Niger (2003) Senegal (1999), Tanzania (1998) and Togo (1998) 29. Industrialized nations –
Australia (1997), Belgium (2000), Canada (1997), Denmark (2003), New Zealand (1995), Norway
(1995), Spain (2003), Sweden (1985), United Kingdom (2003) and United State of America have passed laws criminalizing the practice30.
In 1994, Nigeria joined other members of the 47th World Health Assembly to resolve to eliminate
FGM (WHA.10). Steps taken so far to achieve this include: establishment of a multi-sectoral Technical
Working Group on Harmful Traditional practices (HTP), conduct of various studies and national surveys on HTPS, launching of a Regional Plan of action, formulation of a National policy and plan of action which was approved by the federal Executive Council for the elimination of FGM in Nigeria.
The Nigerian Government decided to observe the International Day For Zero Tolerance to Female
Genital Mutilation which was declared by the WHO as 6th February every year 13, 22, 32, 33, 53.
61 In order to eliminate FGM in Nigeria, it is necessary to promote awareness of the problem by educating the policy/decision makers, the general public, health workers and those who carry out the practice on all its health and psychosocial consequences. This calls for active involvement of political leaders, professionals, development workers, local communities and their leaders and women groups and organizations 12, 58.
2.10 SECULAR TRENDS
There has been a highly significant secular trend in the incidence of FGM during the last 25 years, with age –specific prevalence rates declining from 75.4% among women aged 45-49 years, to 48.6% among women aged 30-34 years, and 14.56% among women 15-19 years of age 16, 17, 18, 37, 42, 45, 50, 60, 65- 66, 69, 74.
2.11 EFFORTS AT ELIMINATING FGM
Bringing an end to the practice of FGM is a long and difficult process requiring long term commitment to establish a foundation for sustained behaviour change8, 22, 38.
The WHO identifies six critical elements that must be emphasized if efforts to abandon the practice are to succeed.
The six elements are 38:
Strong and capable institutions implementing anti FGM programmes at the national, regional
and local levels.
A committed government that supports FGM elimination with positive policies, laws and
resources.
62 Mainstreaming of FGM prevention issues into national reproductive women’s health and
literacy development programmes.
Trained staff that can recognize and manage the complications of FGM.
Coordination among governmental and non-governmental agencies.
Advocacy efforts that foster a positive policy and legal environment, increased support for
programmes and public education.
Over the past two decades, FGM elimination has gained increasing recognition as a health and human rights issue among governments, the international community and amongst professional health associations. As a result of concerted efforts by individuals, non-governmental organizations and the
United Nations, a global, regional and national consensus against FGM has gradually emerged.
There is need to re-orient the communication strategies from awareness raising to behaviour intervention approaches. Current strategies on FGM prevention are based on the message that FGM is a harmful traditional practice that has negative health consequences for women and girls. This message does not address the core values, the myths or the enforcement mechanisms that support this practice.
If success is to be achieved, anti FGM programme implementers must focus on understanding and dismantling the mental map.
FGM is a deeply imbedded cultural practice. Its elimination requires an understanding of the culture, the perception, and the beliefs that have sustained FGM through the millennia.
The most effect programmes have focused on community-based behaviour change.
Community-based projects have used one or several of the five following approaches 58:
63 1. Integrating FGM abandonment into a range of social and economic development initiatives that focus on women’s empowerment
2. Developing alternative rituals to substitute for the traditional cutting ceremonies.
3. Empowering women through participatory techniques to collectively decide about FGM and to negotiate community support.
4 Using an intensive social marketing approach to involve community stakeholders in evaluating
the cost and benefits of continuing or abandoning FGM
5. Identifying individuals who have challenged or “deviated” from conventional
societal expectations and explored successful alternatives to cultural norms, beliefs, or perceptions
in their communities.
58 Four promising community-based projects include:
1. The Coptic Evangelical Organization for Social Services (CEOSS) in Egypt. This has existed for
50years and is renowned for its program to empower rural women. It established an anti –FGC
program in 1995 using an educational program targeting all family members and focuses special
attention on girls ages 7-13 at risks of excision and their mothers
2. The Maendeleo Ya Wanawake Organization (MYWO in Kenya). This was formed in 1952 with the
objective of improving the living standard of families and communities in Kenya. It uses the
alternative coming of age rites to encourage FGM abandonment
3. Tostan in Senegal. This is an international educational nongovernmental organization established in
1991. Tostan means breakthrough in the Senegalese language of Wolof. It empowers people
through education and knowledge to enhance their personal and community development.
64 4. The Reproductive, Education, And Community Health (REACH) program in Uganda. This was
formed in 1995 and sensitizes the elders about the harmful effects of FGM. as s result the elders
resolved to replace the actual cutting with symbolic gift giving and other festivities to mark the
passage in adulthood
65 CHAPTER THREE
3.1 MATERIALS AND METHOD
3.2 STUDY DESIGN This was a cross sectional study involving all women in the obstetrics and gynaecology
clinic in Baptist Medical Centre, Eku, Delta State over a period of six months (September
2002 to February 2003).
3.3. LOCATION OF STUDY:
The study was carried out in the obstetrics and gynaecological unit of the
Baptist Medical Centre, Eku. The Hospital is a one- hundred- and- seventy- bed rural mission hospital in Delta State of Nigeria established in 1950. It is located in Ethiope East Local Government Area of the state. It serves as a general hospital to surrounding rural villages as well as referral center for clients from Warri, Sapele, Ughelli and their suburbs and even beyond. The major tribes living in these areas are the Urhobos,
Ijaws, Itsekiris, Isokos and Ukwanis.
3.4 SELECTION:
3.4.1 INCLUSION CRITERIA 1. The criteria included selected outpatient women of the reproductive age group between
ages fifteen and forty-nine who attended the obstetrics and gynaecology clinic during the
period of study because they constituted the bulk of patients seen in this clinic.
3.4.2 EXCLUSION CRITERIA:
1. Patients outside the reproductive age.
2. Patients refusing interview and examination.
66 .
3.5 ESTIMATION OF SAMPLE SIZE
The sample size was estimated from the formula96: 2 2 η = Zα pq/d where η = minimum sample size
Zα = level of significance at 5%
p = prevalence
q = 1- p
d = precision limit
Using 50 percent prevalence of mutilated women 2, 10, 13, 30, the minimum sample size 2 η = 1.96 x 0.5 x 0.5 = 384
2 . (0.05)
There was no attrition because there was no need for follow-up.
3.6 SAMPLING METHOD
3.6.1 SAMPLE FRAME:
From the Hospital records, 42 patients were seen on the average on general clinic days being Mondays,
Wednesdays and Fridays. This gives a figure of 126 patients per week or 504 per month. The sample frame over six months therefore was 3024 patients.
67
3.6.2 FIRST SAMPLE AND SAMPLE INTERVAL:
The first sample was selected through the process of simple random sampling in which all the clients present at the clinic at the commencement of the study handpicked numbers 1 to 50 written in pieces of papers folded and put in a polythene bag. The client who picked number 1 became the first subject.
The sample interval was now derived by division of the sample frame by the estimated sample size
3024/383. This equals 7.90 approximately 1in 8.
3.7 DATA COLLECTION.
A structured interviewer - administered questionnaire (appendix III) was used to obtain information about the socio-demographic background of the women, their knowledge and experiences of FGM and its complications, their reproductive and birth history and attitudes and practices relating to FGM. The questionnaire resulted from a focused pilot group discussion which determined the pattern of response.
At the completion of the interviews, the women were clinically examined by the researcher on a delivery-like examining couch in the lithotomy position with a good 60-watt angle poised lamp (made in England) model 90 in the presence of a nurse chaperone. They were covered with linen from lower abdomen to knee. A pair of disposable gloves was worn and the introitus parted to view the clitoral/vaginal region and the presence or absence of FGM confirmed and the WHO Classification system used to allocate the type of FGM. The patients were health educated.
3.8 DATA ANALYSIS
68 The data was analyzed by computer using the statistical package for social sciences software (SPSS) version 17. The frequencies of categorical variables were determined. Circumcision index (C.I) that is, the ratio of circumcised to uncircumcised respondents was used to assess the trend of the practice. Chi- square(X2) test was employed for comparing differences in proportions or for testing significance of associations. Odds ratio was used to determine the strength of association between being circumcised and complications of FGC. The level of statistical significance was taken as p<0.05.Tables and charts were constructed for the presentation of results.
3.9 ETHICAL CONSIDERATION
The approval of the Ethical Committee of the Eku Baptist Hospital to carry out this study was sought and clearance was obtained. Attached to this dissertation, is a copy of the ethical clearance (Appendix
I). Detailed explanation of the importance of the research was done to each subject eligible for the study and their approval and written consent (Appendix II) was obtained before inclusion into the study.
69 CHAPTER FOUR
RESULTS
A total of three hundred and eighty four respondents made up of 290 pregnant (75.50%) and 94 non- pregnant (24.50%) participated in this study as shown in figure 4.1.
4.1 SOCIODEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS
The ages of the respondents ranged between 16 and 45 years with a mean of 30.41 ± 6.36years. Table
I shows the age distribution and circumcision status of respondents. Majority of the respondents were in the 25-29 (29.2%) and 30 -34 (27.6%) years age bracket.
70
TABLE 1: Age distribution and circumcision status of respondents.
Age Circumcised Uncircumcised Total CI ratio bracket(yrs) N (%) N (%) 16-19 7(2.5) 8(7.8) 15(3.9) 0.88 20-24 30(10.6) 20(19.6) 50(13.0) 1.50 25-29 77(27.3) 35(34.3) 112(29.2) 2.2 30-34 88(31.2) 18(17.6) 106(27.6) 4.8 35-39 50(17.7) 15(14.7) 75(16.9) 3.3 40-44 27(9.6) 5(4.9) 32(8.3) 5.4 45-49 3(1.1) 1(1) 4(1.0) 3.0 TOTAL 282(100) 102(100) 384(100) 2 X =18.672, df =6, p-value= 0.005.
The association of age with circumcision status was statistically significant. The overall trend in circumcision practice (circumcision index) was obviously downward judging from the lower index among respondents of the lower age range 16-19 years (C.I., 0.88) compared to those of the older age of 25 years and above (C.I., 2.2)
71
Table 2: Parity distribution and circumcision status of respondents.
P value Parity Circumcised Uncircumcised Total (%) C.I None 87(22.7) 58(15.1) 145(37.8) 1.5 0.001 One 74(19.3) 16(4.2) 90(23.4) 4.63
Two 38(9.9) 9(2.3) 47(12.2) 4.22 Three 28(7.3) 7(1.8) 35(9.1) 4
Four 22(5.7) 7(1.8) 29(7.6) 3.14
Five 10(2.6) 2(0.5) 12(3.1) 5 > five 23(6.0) 3(0.8) 26(6.8) 7.66 Total 282(73.4) 102(26.6) 384(100) 2 X =22.778, df = 6, p-value=0.001.
There was statistically significant difference between female circumcision and parity.
Table 2 shows the parity distribution of respondents for circumcision status. A total of 145(37.8%) respondents were nulliparous while 90(23.4%) of respondents had one child. The circumcision index in the zero parity group (C.I., 1.5) was lower compared to that of the multi-parity group (C.I., 4.22).
72
Table 3: Social class distribution and circumcision status of respondents.
Circumcised Uncircumcised Total Social class N (%) N (%) N (%) C.I class 1 96(25) 57(14.8) 153(39.8) 1.68 class 2 64(16.7) 17(4.4) 81(21.1) 3.77 class 3 65(16.9) 21(5.5) 86(22.4) 3.1 class 4 43(11.2) 3(0.8) 46(12.0) 14.33 class 5 14(3.6) 4(1.0) 18(4.7) 3.5
Total 282(73.4) 102(26.6) 384(100) 2.76 2 X =22.778, df = 6, p-value=0.001.
The association between social class and circumcision status was statistically significant
Table 3 shows the social class distribution of respondents for circumcision status. Majority of the 384 respondents were in social class 1, II and III. The circumcision index in the higher social class group
(C.I., 1.68) was lower compared to that of the lower social class group (C.I., 3.77).
73
Table 4: Tribe distribution and circumcision status of respondents.
Circumcised Uncircumcised Total Tribe N (%) N (%) N (%) C.I.
Urhobo 184(47.9) 42(10.9) 226(58.9) 4.38
Isoko 11(2.9) 12(3.1) 23(6.0) 0.92
Ukwani 18(4.7) 3(0.8) 21(5.5) 6.0
Edo 2(0.5) 7(1.8) 9(2.3) 0.29
Ijaw 6(1.6) 4(1.0) 10(2.6) 1.5
Itsekiri 1(0.3) 9(2.3) 10(2.6) 0.11
Ibo 33(8.6) 14(3.6) 47(12.2) 2.36
Yoruba 3(0.8) 4(1.0) 7(1.8) 0.75
Ibibio 3(0.8) 0(0.0) 3(0.8) 0.0
Ishan 4(1.0) 3(0.8) 7(1.8) 1.33
Tiv 6(1.6) 0(0.0) 6(1.6) 0.0
Igala 1(0.3) 0(0.0) 1(0.3) 0.0
Idoma 10(2.6) 4(1.0) 14(3.6) 2.5
Total 282(73.4) 102(26.6) 384(100.0) 2.764706
74 2 X =62.549, df = 13, p-value= 0.000.
There was statistically significant association between tribe and female circumcision.
In this study, the vast majority 226(58.9%) of respondents were Urhobos as shown in table 4. This was followed by 47(12.2%) respondents from Ibo. 7(1.8%) respondents were from Yoruba. There was no respondent from Hausa.
Table 5: Distribution of marital status and circumcision status of respondent.
Marital Circumcised Uncircumcised Total C.I. p-value status N (%) N (%) N (%)
Single 46(16.3) 30(29.4) 76(19.8) 1.53
0.003
Married 234(83.0) 69(67.6) 303(78.9) 3.39
Divorced 2(.7) 3(2.9) 5(1.3) 0.67
Total 282(100) 102(100) 384(100) 2.77
2 X =11.592, df = 2, p-value= 0.003
There was statistically significant association between marital status and female circumcision.
Table 5 shows the distribution of the respondents marital and circumcision status. 234(83.0%) of the circumcised respondents were married while 46(16.3%) were single.
75
Table 6: Distribution of religion and circumcision status of respondents.
Circumcised Uncircumcised Total CI p-value
Religion N (%) N (%) N (%)
Christianity 269(95.4) 101(99.0) 370(96.4) 2.66
Islam 6(2.1) 0(0.0) 6(1.6) -
Traditional 4(1.4) 1(1.0) 5(1.3) 4 0.325
Others 3(1.1) 0(0.0) 3(0.8) -
Total 282(100) 102(100) 384(100) 2.77
2 X =3.46, df = 3, p-value = 0.325.
There was no statistically significant association between religion and female circumcision.
76 Table 6 shows the distribution of the respondents’ religion and circumcision status. Out of the 370
Christian respondents, 72.7% of them were circumcised whereas 100% of the Moslems were circumcised. Eighty percent of those in traditional religion were circumcised.
Table 7: Distribution of educational status and circumcision status of respondents.
Education Circumcised Uncircumcised Total CI p-value
N (%) N (%) N(%)
None 3(2.9) 19(4.9) 5.3 16(5.7) primary 43(15.2) 7(6.9) 50(13.1) 6.14 secondary 119(42.2) 34(33.3) 153(39.8) 3.5 0.003 tertiary 104(36.9) 58(56.9) 162(42.2) 1.79
Total 282(100) 102(100) 384(100)
77 2 X =13.743, df = 3, p-value=0.003.
There was statistically significant difference between educational status and female circumcision.
From Table 7 above, it can be seen that majority of the respondents had secondary and tertiary education. 19(4.9%) had no formal education. The circumcision index was higher in the lower educational status than those with higher educational status.
TABLE 8: Distribution of circumcised respondents and age at circumcision
Age at circumcision Frequency (N) Percentages (%)
<1year 66 23.40
1-4years 1 0.40 5-9years 9 3.20 10-19years 178 63.10 >20years 28 9.90 Total 282 100 2 X = 384, df =4, p-value=0.000
78 There was a statistically significant association between being circumcised and age at circumcision
Table 8 above showed that 178(63.1%) of the circumcisions were done between the age ranges of 10-
19 years while 66(23.4%) were circumcised less than one year.
4.2 CLINICAL FINDINGS
The prevalence of the FGC among the 384 respondents was 73.4% as shown in fig 4.2
79
Type I mutilation was the commonest observed in the study as shown in figure 4.3. There was no type
1V mutilation.
80 4(1.40%)
78(27.70%) type 1 type 2 200(70.90%) type 3
Fig. 4.3: Pie chart showing the prevalence of the type of circumcision.
81 Figure 4.4 below shows that the more educated the respondent, the less likely the citing of tradition as reason for FGC.
120.00%
100.00% 100.00% 100.00% 90.30% 83.10% 80.00%
60.00%
40.00%
16.90% 20.00% 9.70% Tradition 0.00% 0.00% Not tradition
Respondents citing tradition(%) 0.00% None 1 11 111
Educational status of respondents Fig. 4.4: Bar chart showing the frequency of respondents by educational status citing tradition as reason for circumcision.
82
4.3 ATTITUDES OF RESPONDENTS TABLE 9: Distribution of respondents’ and daughters’ circumcision status.
Respondent Respondent not Total circumcised circumcised N (%) N (%) N (%)
Daughter 26(9.2) 0(0) 26(6.8) circumcised Daughter not 256(90.8) 102(100) 358(93.2)
circumcised Total 282(100) 102(100) 384(100)
2 X = 10.087, df = 1, p-value= 0.001.
It was observed from table 9, that 26 (9.2%) of the circumcised respondents had already circumcised their daughters.
There was statistically significant association between being circumcised and daughters’ circumcision.
83
TABLE 10: Distribution of respondents’ circumcision status and intention to circumcise daughters.
Circumcised (%) Uncircumcised (%) Total Intend to 93(24.2) 3(0.8) 96(25.0) circumcised daughter Do not intend to 181(47.1) 99(25.8) 280(72.9) circumcise Not sure 8(2.1) 0(0.8) 8(2.1) Total 282(73.4) 102(26.6) 384(100)
2 X = 41.030, df = 2, p-value= 0.000
There was a statistically significant association between being circumcised and intention to circumcise daughters.
The result in table 10 above showed that 93 (24.2%) of the circumcised respondents said they would circumcise their daughters in future.
84
TABLE 11: Distribution of respondents’ support for ban of the practice.
Circumcised Uncircumcised Total P-value N (%) N (%) Support ban 209(74.1) 95(93.1) 304(79.2) Do not 66(23.4) 7(6.9) 73(19.0) 0.000 Support Ban Not sure 7(2.5) 0(0) 7(1.8) Total 282(100) 102(100) 384(100)
2 X = 16.738, df = 2, p-value= 0.000.
There was statistically significant association between being circumcised and support of ban of practice.
It was observed in table 11 above that the uncircumcised respondents 95 (93.1%) were more in support of banning the practice.
85
TABLE 12: Distribution of respondents’ educational status and ban of practice.
Educational Support ban Do not Not sure Total (%) p-value status N (%) support ban N (%) N (%) None 14(3.6) 5(1.3) 0(0) 19(4.9) 0.000 Primary 29(7.6) 18(4.7) 3(0.8) 50(13.0) Secondary 114(29.7) 35(9.1) 4(1.0) 153(39.8) Tertiary 147(38.3) 15(3.9) 0(0.0) 162(42.2) Total 304(79.2) 73(19.0) 7(1.8) 384(100) 2 X = 32.104, df = 6, p-value= 0.000.
There was a statistically significant association between education and ban of practice.
The more educated the respondent the more likely they are to support ban of the procedure.
86
TABLE 13: Distribution of respondents’ social class status and ban of practice.
Don't Support support Social ban ban Not sure class N (%) N (%) N (%) Total p –vavue
Class I 139(45.7) 14(19.2) 0(0) 153(39.8)
Class II 66(21.7) 14(19.2) 1(14.3) 81(21.1)
Class III 62(20.4) 22(30.1) 2(28.6) 86(22.4)
Class IV 24(7.9) 18(24.7) 4(57.1) 46(12.0)
Class V 13(4.3) 5(6.8) 0(0) 18(4.7)
Total 304(100) 73(100) 7(100) 384(100) 0.000 2 X = 43.317, df = 4, p = 0.000
There was a statistically significant association between social class and ban of practice.
The higher the social class of the respondent the more likely they were to support ban of the procedure.
87
4.4 PRACTICES OF RESPONDENTS
TABLE 14: DISTRIBUTION OF RELATIONS WHO TOOK RESPONDENTS FOR
CICUMCISION
Who took for N % P value circumcision
Mother 233 82.6
Grand mother 11 3.9
Step Mother 2 0.7
Sister in law 3 1.1
Sister 2 0.7 0.000
Aunty 18 6.4
Self 9 3.2
88 Father 4 1.4
282 100 2 X = 384.000, df = 8, p-value= 0.000
As shown in Table 14, mothers were responsible for requesting for the procedure in 233(82.6%) out of the 282 circumcised respondents.
There was statistically significant association between being circumcised and who took them for circumcision.
.
Figure 4.5 below showed that consent was obtained in 147(52.1%) of the circumcised respondents while it was not in 131(46.5%) of them.
89 4(1.40%)
131(46.50%) 147(52.10%)
yes
no
don't know
Fig. 4.5: Pie chart showing the percentage of circumcised respondents and consent obtained
In figure 4.6 below, 151 (53.5%) of the circumcisions were done by qualified nurses, 40 (14.2%) by traditional birth attendants, 24 (8.5%) by traditional healers, 8 (2.8%) by medical doctors and 11 (3.9%) by chemists.
90
Figure 4.7 below showed that scissors was the most common instrument used for circumcision in 99 (35.1%) of cases, followed by razor blade in 35 (12.4%) of cases, then knife in 22 (7.8%) of
91 cases, surgical blade in 13 (4.6%) of cases and only 1 (0.4%) was done using snail shell. However, 112 (39.7%) of respondents did not know the instrument that was used.
45.00% 39.70% 40.00% 35.10% 35.00%
30.00%
25.00%
20.00%
15.00% 12.40%
10.00% 7.80% Circumcised respondents(%). 4.60% 5.00% 0.40% 0.00% Razor Scissors Knife Snail Surgical Don't blade shell blade know Instrument used.
Fig. 4.7: Bar chart showing the percentage of circumcised respondents and instrument used.
92 The result presented in figure 4.8 below showed that 204(72.4%) of the circumcised respondents did not know about the sterility of the instrument used. Only 68(24.1%) said it was sterile while 10(3.5%) said it was not.
80.00% 72.40% 70.00%
60.00%
50.00%
40.00%
Response(%) 30.00% 24.10%
20.00%
10.00% 3.50% 0.00% Yes No Don't know
Knowledge of steritlity of instrument used. Fig. 4.8: Bar chart showing the percentage of circumcised respondents and knowledge of sterility of instrument used. .
93 The result in figure 4.9 showed that 170(60.3%) of the circumcisions were done under some form of anaesthesia. In 29(10.3%) respondents it was done without anaesthesia while in 80(29.4%) it was equivocal.
70.00% 60.30% 60.00%
50.00%
40.00%
29.40% 30.00%
20.00% 10.30%
10.00% Response of circumcised Response circumcised of respondents(%) 0.00% Yes No Don't know Use of anaesthesia. Fig. 4. 9: Bar chart showing the percentage of circumcised respondents and use of anaesthesia.
94
TABLE 15: Distribution of respondents and type of anaesthesia used.
Type of Anaesthesia used Frequency N (%) local 162(57.7)
General 14(5.0)
Both 3(1.1)
None 34(12.1)
Don’t Know 69(24.5)
Total 282(100)
In table 15 above, 162(57.3%) circumcised respondents had local anaesthesia while 14(5.0%) had general anaesthesia. 3(1.1%) had both local and general anaesthesia. 34(12.1%) had no anaesthesia and
69(24.5 %) did not know whether they were given anesthesia.
95
From figure 4.10 below, the procedure in majority of the circumcised respondents 58(20.6%) lasted for 10minutes, while in minority of them 4 (1.40%) the procedure lasted for 25minutes. 102(36.2%) of circumcised respondents did not know how long the procedure lasted.
40.00% 36.20% 35.00% 30.00%
25.00% 20.60% 20.00% 13.80% 15.00% 11.70% 10.00% 6.40% 7.10% 5.00% 1.40% 2.80%
0.00% percentage of circumcised respondents
Duration of procedure (mins) Fig. 4.10: Bar chart showing the percentage of circumcised respondents and duration of procedure.
96
The result in figure 4.11 showed that herbs were used in control bleeding in 157(56%) of respondents while cotton wool or gauze was used in 99(35%) of respondents. Sutures were used in 23(8%) of respondents and penicillin powder was used in 3(1%) of respondents.
3(1%)
99(35%)
157(56%) herbs sutures 23(8%) cotton wool/gauze penicillin powder
Fig. 4.11: Pie chart showing the percentage of circumcised respondents and material used to arrest bleeding
97
The result in figure 4.12 showed that 147(52.1%) of the procedure was carried out in the village while 124(44.0%) was done in township. 11(3.9%) did not know where it was done.
60.0%
52.1% 50.0% 44.0%
40.0%
30.0%
20.0%
10.0%
percentage of circumcised respondentse 3.9%
.0% village township don't know Venue of procedure Fig. 4.12: Bar chart showing the percentage of circumcised respondents and venue of procedure.
98
The result in figure 4.13 showed that 128(45.4%) of the procedure was done in the Hospital while 137(48.6%) was at home. 17(6%) of respondents did not know where it was done.
17(6.00%)
128(45.40%)
137(48.60%) hospital home don't know
Fig.4.13: Pie chart showing the percentage of circumcised respondents and facility of circumcision.
99
Tradition was the major reason given for circumcision in 210 (74.5%) of subjects as shown in figure
4.14; this was followed by prevention of promiscuity 32 (11.3%).The least reason given was cosmetic
3 (1.1%).
80.0% 74.5% 70.0% 60.0% 50.0% 40.0% 30.0%
20.0% 11.3% 10.0% 6.7% Reasons Reasons for circumcision (%) 1.1% 2.8% 1.4% 2.1% .0%
Reason for circumcision
Fig. 4.14: Bar chart showing the variation of reasons given by circumcised subjects for circumcision.
100
4.5 COMPLICATIONS
The result of immediate complications in figure 4.15 showed that pain was the commonest in 102 (36.2%) of circumcised respondents. This was followed by bleeding in 15 (5.3%) of cases.
101 40.0% 36.2% 35.0% 30.9% 30.0% 25.5% 25.0%
20.0%
Percentage 15.0%
10.0% 5.3% 5.0% .7% .7% .7% .0% pain bleeding shock infection dysuria don't nil know Immediate complications.
Fig. 4.15: Bar chart showing the frequency of immediate cmplication among circumcised subjects
The gynaecological complications among respondents were generally low as seen in figure 4.16. The highest recorded complication was infertility in 21(7.4%) circumcised and 9 (8.8%) uncircumcised respectively
102 90 85.5 80
70 62.7 60 50 40 circumcised uncircumcised 30 20 6.9 7.48.8 gynaecological gynaecological complications(%) 5.9 10 5 2.82.9 2.1 0.4 0 1.4 0 0
Gynaecological complications
Fig.4.16: Frequency of gynaecological complications among respondents.
103 Results of obstetric complications among respondents are presented in figure 4.17 below. It was observed that the percentage of obstetric complication was generally low among circumcised and uncircumcised subjects. There was no complication in 97.5% and 97.1% of the circumcised and uncircumcised respondents respectively. No significant difference was observed in the various obstetric complications with circumcision status (p >0.05). Odds ratio (OR) for obstructed labour =
1.087 95% CI .216- 5.474 and for still birth = 2.196, 95% CI .261- 18.462. An Odds ratio > 1 implies that obstructed labour and still birth was more likely among mothers who were circumcised.
1.80% 1.60% 1.60% 1.60% 1.40% 1.20% 1.00% 0.80% 0.80% 0.50% 0.60% circumcised 0.40% 0.30% not circumcised
Percentagerespondents. 0.20% 0%0% 0% 0.00% obstructed vvf birth asphyxia still birth labour
Obstetric complications. Fig. 4.17: Percentage respondents and obstetric complications.
104 It was also observed that psychological complications were generally higher among the circumcised than uncircumcised as seen in figure 4.18. The commonest psychological complication was loss of interest in sex.
105
As is shown in figure 4.19, as the educational status of the respondents increased, their intention not to circumcise their daughters increased from 11(2.9%) in those without formal education to 31(8.1%) in those with primary education, 96(25%) in secondary and 142(37%) in tertiary education.
106 CHAPTER FIVE
DISCUSSION
The prevalence of female genital mutilation among the three hundred and eighty four respondents in this study was 73.4%. This is comparable to the figures of 75.8% reported in Egypt 93 and 72.5% in
Tanzania15. It is higher than 60.4% 13 and 69.9% 28 quoted from the Eastern and Western parts of
2 87 Nigeria respectively. It is also higher than 44% and 30% reported from studies carried out in Delta state of Nigeria. The differences observed could be due to the geographical and cultural backgrounds of the study population. The national prevalence dropped from 50% 2, 10, 13 in the year 2000 to 19.1%
16 which is the current national prevalence. This drop is probably due to the global campaign against
FGM 5, 16.
The age range of the study population was 15-49 years with a mean age of 30.41 ± 6.36 years. This age range is similar with the study by Nkwo and Onah79 who got a prevalence of 35.4%. The sample size, study design, geographic regional setting and socio-cultural practice with respect to FGM may have accounted for the difference in prevalence.
The circumcision trend or index among various groups revealed a drop from the higher to the lower age bracket as shown in Table I. The drop could be attributed to the higher educational level of respondents in the lower age bracket observed in this study. This was in agreement with the observation of other workers 64, 65, 69, 87, 89. As the respondents’ educational status increased, the intention not to circumcise their female children increased as shown in Figure 4.19. This was the finding by other researchers 44,65,69,80. This may be as a result of increase in awareness of the dangers of FGM brought about by educational attainment. A statistically significant number of respondents with higher
107 educational level were in support of the ban compared to those of lower educational level as shown in table 12. Rahlenbeck and Mokennen69 found out that women who had ever attended a school had a 4- fold increase in the odds of disapproving the practice than those who never did. Thus improved education will go a very long way in changing the attitude of people toward FGM and should be one of the focal points of anti FGM campaigners. In the same vein women of low socioeconomic status
(social class IV and, especially, V) were more favourably disposed to practicing this condition than the elites (class I and II) as shown in table 13. Rahlenbeck and Mokennen also found out that women who scored high on empowerment indices had a 1.5-fold increase in the odds of disapproving the practice compared to those scoring low. Poverty, illiteracy and low status of women are closely linked to FGM
16, 23.
In this study, types I and II were the commonest genital cutting as shown in figure 4.3. This finding was similar with those of some workers 28, 50, 85, 86. Types 1, II and III of genital cuttings were found mostly amongst the Urhobo tribe. This was closely followed by the Ibo tribe with types I and II only.
This corroborates earlier reports that the type of circumcision depends on the geographical location of the society in question 11, 21, 50. It is documented that in the southwest of Nigeria, type I is the commonest 12. In the Eastern region, it is mostly type II that is found whereas in the Northern part, the type ranges from I to IV but commonly type IV. Because extreme complications are not as common with clitoridectomy (types I and II) as they are with infibulation (types III and IV), clitoridectomy is more frequently performed as it is falsely perceived as safe.
Christians formed 96.4% of this study population. The difference observed among the religious groups was not statistically significant (p=0 .325).
108 A total of 40.1% of circumcised respondents reported immediate complications. This was lower than that reported by Dare et. al.4 but higher than the figure reported by Mandara9. Pain and bleeding were the most significant complications experienced by the respondents. This agreed with findings of
Mandara9.
A total of 79.2% of the respondents were firmly opposed to the practice and wanted it banned. This was close to the figure reported by Feyi-Waboso and Akinbiyi 13. The reason for this high level of opposition may be due to current campaign against FGM which has helped to increase awareness in
Nigeria 8, 13, 22, 32, 33. In spite of this, 24.2% of circumcised respondents still intended to cut their daughters as shown in Table 10. This was similar to the figure reported by Msuya and co-workers50 but higher than reports by other workers 4, 13, 44, 84. Also it was observed that the practice of FGM was significantly lower in daughters of uncircumcised mothers than in those of circumcised mothers as shown in Table 9. These findings have important implications when considering strategies for the elimination of harmful traditions.
According to studies by some researchers 41, 64, men were more likely than women to favour discontinuation. The occurrence of complications and global campaigns against FGM were the major reasons given for supporting the ban of the practice. Tradition remained the main reason given by respondents for not supporting the practice. Ways and means need to be discovered to influence tradition. Some groups are encouraging communities for alternatives to FGM without giving up its social and ritual aspects. For example the Maendeleo Ya Wanawake Organization (MYWO) project in
Kenya worked with opinion leaders of the secret genital cutting societies to educate them about the harmful effects of FGM and to encourage allowing a rite of passage for the adolescent girls into
109 womanhood including the celebration, giving of gifts and recognition while omitting the actual harmful operations 58.
The age of circumcision varies and depends on the ethnic group. In this study, a total of 178(63.1%) were circumcised between the age range of 10-19 years while 66(23.4%) were circumcised on the eight day of life as shown in Table 8. This was in agreement with the studies by some researchers 28, 88.
The mothers were the ones cited most 233(82.6%) as those who took their children for circumcision.
The aunties and grandmothers also played significant roles in perpetuating this practice. Only 1.4% of fathers were implicated in this study as shown in Table 14.
This study showed in figure 4.5 that consent was obtained in 52.1% of circumcised respondents. The respondents may have consented on the grounds of tradition which was the commonest reason cited for the procedure.
In the work done by Feyi-Waboso and Akinbiyi13, elderly women performed 57.1% of the operations while in the study carried by Oduwole and Iyaniwura28, 68.3% of the operations were done by traditional birth attendants. In the research carried out by Satti and coworkers 89 all the operations were done by midwives. In this study as shown in figure 4.6, qualified nurses performed majority of the operations (53.5%). Medical doctors were involved in only 2.8% of the operations. This figure is quite low compared to 34% quoted by Ugboma and co-workers29 in Port-Harcourt. In spite of the lower figures given for medical personnel in this study, especially doctors, the fact still remain that medicalization of the procedure is wrong and has been prohibited by the World Health Organization.
Carrying out FGM in hospital by qualified nurses / midwives and doctors may reduce the risk of exposure to HIV infection (if instruments are sterilized) and probably limit the extent of the operation
110 to the less extensive type I. However, it deprives the non-consenting girl of her fundamental human rights against bodily harm and may not reduce or completely remove some consequences that circumcised women suffer later on in life such as keloid formation and reduced or lack of sexual satisfaction 31, 49. Every medical personnel should therefore uphold the integrity of his / her profession and abide by the WHO stand 58.
This study showed that FGM had statistically significant association with obstetrics complications including obstructed labour p ≤ 0.05, and birth asphyxia p ≤ 0.05. It also had a statistically significant association with psychological complications including sadness p ≤ 0.05, fear p ≤ 0.05, loss of interest in sex p ≤ 0.05 and anger p ≤ 0.05. It however had no significant association with gynaecological complications.
111 RECOMMENDATIONS:
1. Advocacy: This should be undertaken at the political level, among health and social workers and in communities. Short and simple information pamphlets for use in lobbying at these different levels can be extremely useful. At the national level, seminars and workshops should be organized and sponsored, and there should be public awareness and enlightenment campaigns involving the national and state media. This will facilitate substantial dissemination of information through write- ups, drama and film production highlighting the harmful effects of FGM.
2. Girl child education: There is need for emphasis to be placed by the Government on female education since education has strong influence on reproductive health generally.
3. Community participation: Traditional institutions like chiefs, traditional circumcisers, traditional healers, women opinion leaders, market women and men folk should participate in designing and implementing effective reforms.
4. There should be routine health talks in the antenatal/ gynaecological units to counsel and educate clients on reproductive health issues especially female genital mutilation.
5. Enlightenment campaign should be embarked upon by government to encourage mutilated women for hospital delivery.
6. The various houses of assemblies should enact laws to ban the procedure and its medicalization.
7. A substitute ceremony should be instituted in place of the actual circumcision.
8. An improvement of the general living standards and socioeconomic status of the populace by creating employment opportunities and reducing the cost of living for the people would ameliorate the poverty factor which has great impact on health.
112 9. Further research should be conducted to document every aspect of FGM.
10. Working partnerships: associations and organizations should complement each others efforts at eliminating FGM as expertise may differ in experience in programmes, advocacy and service provision.
113 LIMITATIONS OF STUDY.
1. The hospital based nature of this study limits the application of the results to the
general population hence a community based study may be appropriate.
2. The clinic based study may have missed older women who are no longer
attending reproductive health care clinics and might have influenced the overall prevalence
rate
3. Local studies on the prevalence of female genital mutilation were few.
114
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\
125 APPENDIX I th 8 June, 2000.
The secretary,
Faculty of General medical practice,
National Postgraduate Medical College,
Kilometre 26, Lagos – Badagry Expressway
P.M.B. 2003
Ijanikin.
Lagos.
Dear sir/Madam,
ETHICAL COMMITTEE CLEARANCE
RE: DR E.T.OMU
This is to certify that the proposal ‘’ the Prevalence, Severity and Rationale of the practice of female genital mutilation as seen at the Baptist Medical Centre Eku ‘’ by Dr E.T.Omu has been approved by the Ethics Committee of this institution.
Thanks
Yours Sincerely,
Dr S.K. Nkor
Chairman Ethics Committee
126
APPENDIX II
CONSENT FORM
SERIAL NO: ………….
Consent to participate in the study: The prevalence, severity and rationale of the practice of female genital mutilation as seen at the Baptist Medical Centre, Eku, Delta state.
Dear Madam,
My name is Dr E.T.OMU and I am carrying out a study to determine the prevalence, severity and rationale concerning female genital mutilation. All information you give will be kept confidential and your name will not be used. However you are not in any way bound to give your consent. Your non- participation will not affect your treatment or hospital bill.
Kindly indicate your consent to participate in this research by signing or thumb printing in the space provided.
Thank you.
Dr E.T.Omu.
127
APPENDIX III
QUESTIONNAIRE
I am Dr Omu E.T. and I am carrying out a study to determine the Prevalence, Severity and Rationale of the practice of female genital mutilation as seen at the Baptist Medical Centre, Eku, Delta state. Any information given will be treated with utmost confidence
Thanks for cooperation.
KINDLY FILL AS APPROPRIATE
HOSPITAL NUMBER………………………SERIAL NUMBER………………………………
S/NO QUESTIONS
SECTION 1 SOCIODEMOGRAPHIC DATA
1.1 Physiological state Pregnant………………………..………….…
Not pregnant…………………………………
1.2 Age in years
1.3 Age bracket 15-19…………………………………………
20-24…………………………………………
25-29………………………………………...
30-34…………………………………………
128 35-39………………………………………...
40-44………………………………………...
45-49………………………………………...
1.4 Tribe Urhobo…………………………………….
Isoko……………………………………....
Ukwani………………………… …………
Edo……………………………………..….
Ijaw……………………………………..…
Itsekiri…………………………………..…
Ibo………………………………………….
Yoruba……………………………………...
Ika………………………………………….
Ibibio……………………………………….
Ishan…………………………………….…
Bini…………………………………………
Tiv………………………………………….
Igala………………………………………..
Idoma……………………………......
129 1.5 Marital status Single……………………………………….
Married…………………………… ……….
Widow……………………………………...
Divorced…………………………………....
Separated…………………………………..
1.6 Religion Christianity……………………… …......
Islam……………………………………….
Traditional………………………………....
Others (Specify)…………………………..
1.7 Educational status None……………………………………….
Primary…………………………………….
Secondary………………………………….
Tertiary…………………………………….
1.8 Occupational status of woman Professional, Top civil servant…………....
Politician, Business woman……………….
Middle level bureaucrat, technician ………
Skilled artisan, Trader………………….….
Unskilled worker, Housewife……………..
130 Occupational status of husband Professional, Top civil servant…………...
1.9 Politician, Business man………………….
Middle level bureaucrat, technician………
Skilled artisan, Trader…………… …… .
Unskilled worker, Housewife……………
1.10 Social class of woman Social class 1(leading profession)………….
Social class 11 (intermediate profession…. .
Social class111(skilled)… …………………
Social class1V(partly skilled)……………......
Social class V(unskilled)……………………
1.11 Number of children None……………………………… ………..
One…………………………………......
Two………………………………… ………
Three……………………………… ………..
Four………………………………… ………
Five………………………………… ………
> Five……………………………… ………
131 1.12 No of female children None………………………………….……
One…………………………………….….
Two……………………………………….
Three………………………………….…
Four……………………………… ………
Five……………………………………….
> Five…………………………………...…
1.13 Did you undergo circumcision? Yes……………………………………..….
No………………………………… ………
1.14 At what age were you circumcised? Can’t remember……………………………
8 days………………………………………
1year………………………………………..
2years……………………………………….
3years………………………………………
4years………………………………………
5years………………………………………
6years………………………………………
7years………………………………………
8years………………………………………
9years………………………………………
132 10years…………………………………….
11years…………………………………….
12years…………………………………….
13years…………………………………….
14years……………………………… …..
15years……………………………………
16years…………………………………….
17years…………………………………….
18years…………………………………….
19years…………………………………….
20years…………………………………….
21years……………………………………
22years…………………………… ……..
23years……………………………………
24years…………………………….……...
25years…………………………………….
SECTION 2 ATTITUDES
2.1 Would you circumcise your Yes………………………………………….
daughter No…………………………………………..
133 Not sure……………………………….……
2.2 Was your daughter circumcised? Yes……………………………………….…
No………………….……………………….
Not yet………………..……… ……………
2.3 What were the reasons why Complication…………….………………….
daughter (s) were not/would not be Not biblical…………… …..………………
circumcised Global campaign ………………..………….
Out modelled……………………….. …….
Since I was not………… …………….……
See no reason for it……………… …….…
Not our tradition……………. ……………
Will be queried by xren when grown… ….
Depends on father…………….………..…
2.4 What is the reason for circumcising Culture……………..……….……………..
daughter If they want………………………………..
To prevent flirting…………………………
If father says so……………………………
Because I was circumcised………………..
If it will be done in hospita…l…………….
134 Shameful and ugly if not circumcised……
For safe delivery………………… ………
No reason………………...…… …………
2.5 Do you support the ban of the Yes…………………………………………
practice No………………………… …. …………..
Not sure/will think about it……….………..
2.6 What is the reason for supporting Complication……………………………….
ban of the practice Not biblical…………………………………
Global campaign……………… ……… ….
Out modelled……….………………………
Increases promiscuity….……… …………
See no reason for it……….……… ………
If Govt likes/sees that it is not good….…….
Will think over it………………………..….
Saves cost……………….………………….
2.7 What is reason for not supporting Tradition…………………………………
ban of the practice Prevents promiscuity…………………….
No consequence………….………………
Feel women should be circumcised……..
Want to witness it……………………….
135 If trained health personnel will do it…….
No reason………………………………..
Not easy to ban peoples culture………
Will think about it……………………….
SECTION 3 PRACTICES
3.1 Were you pregnant /not pregnant at Not pregnant……….……………………
circumcision Pregnant………………………………...
3.2 Who took you for circumcision Mother………………………………….
Grandmother…….……………………..
Mother in law…………………………..
Step mother………………………….…
Sister in law……………………………
Sister…………………………………...
Aunty…………………………………..
Self……………………………………..
Father…………………………………..
Husband……….………………………
Brother……….………………………..
Don’t know.…………………………...
136 3.3 Was consent obtained? Yes……….…………………………….
No……………………………………...
Don’t know………………………….…
3.4 What was the sex of the Male……………………………………
circumcisionist. Female…….……………………………
Don’t know……….……………………
3.5 What was the educational status of None……………………………………
the circumcisionist. Primary……….…………………………
Secondary…….…………………………
Tertiary……….…………………………
Don’t know……….…………………….
3.6 What is the occupational status of Traditional healer………………….……
the circumcisionist. Traditional birth attendant…..…………..
Qualified nurse…………….……………
Medical doctor…….……………………
Chemist…….…………………………...
Don’t know…..…………………………
3.7 What was the instrument used Razor blade……..………………………
Scissors…………………………………
Knife…………………………………….
137 Snail shell……….………………………
Surgical blade……….…………………..
Piece of glass………..…………………..
Don’t know……………………………...
3.8 Was instrument used sterilized? Yes………………………………………
No………………………………………..
Don’t know……….……………………….
3.9 Was anaesthesia used? Yes………….……………………………..
No……………….…………………………
Don’t know……….……………………….
3.10 What type of anaesthesia was used? Local………….……………………………
General…….……………………………….
Both….……………………………………..
None…..…………………………………….
Don’t know………………………………….
3.11 What was the duration of the 5 minutes…………………………………….
procedure 10 minutes……………………………………
15 minutes……………………………………
138 20 minutes……………………………………
25 minutes……………………………………
30…………………………………………….
>30 minutes…………………………………
Don’t know…………………………………..
3.12 What was used to arrest bleeding Herbs…………………………………………
Suture……….………………………………
Mud…………………………………………..
Ashes…………………………………………
Egg white….………………………………….
Animal dung……….…………………………
Cotton wool/gauze…..…………………....
Penicillin powder……..…………………
Tissue paper……….……………………
Mentholated ointment……...……………
Perm kernel oil…………..………………
Native soap………………………………
Engine oil…………………………………
Pad………………..………………………
139 Snail water…………..…………………....
Nothing……………..…………………….
Don’t know……………………………….
3.13 Where did the circumcision take Village…………………………………….
place Township………………………………….
Don’t know………………………….……
3.14 In which facility was the Hospital…………………………………
circumcision done Home……………………………………
Don’t know……………………………….
SECTION 4 COMPLICATIONS
4.1 WHAT WAS THE IMMEDIATE Pain………………………………………
COMPLICATIONS Bleeding…………………………………
Shock……………………………………
Infection…………………………………
Difficulty with urination ………………
Don’t know………………………………
None……………………….……………
140 4.2 Which gynaecological problem did Chronic pelvic pain………………………
you experience? Pain during intercourse……………………
Menstrual pain………….…………………
Infertility………………………………….
Keloid…………………………………….
None…………..………………………….
Others (specify)…………………………..
4.3 Which obstetric problem did you Obstructed labour…………………………
experience? Vesicovaginal fistula……………………..
Birth asphyxia…………………………….
Still birth…………………………………..
Nil…………………………………………
Others……………………………………..
4.4 Which psychological problem did Sadness……………………………………
you experience? Fear……………………………………….
Loss of interest in sex…………………….
Anger…………………………………….
Worry…………………………………….
Sleep disturbance………………………….
Nil…………………………………………
141 SECTION 5 PHYSICAL EXAMINATION
5.1 Type of circumcision Type 1……………………………………..
Type II……………………………………..
Type III………………………………….....
Type IV…………………………………….
Normal external genitalia………………..…
142