FGM – Female Genital Mutilation Kvinnlig Könsstympning

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Senior FGM – Female Genital Mutilation Kvinnlig Könsstympning

Dr. med. Johannes Leidinger, MD., MPH.

Senior Consultant in Gynaecology and Obstetrics Överläkare på Kvinnokliniken Södersjukhuset Stockholm & Mälarsjukhuset Eskilstuna Lehrbeauftragter/Dozent der Ludwig-Maximilians-Universität München 16 days of activism 2016

From 25 November, the International Day for the Elimination of Violence against Women, to 10 December, Human Rights Day, the 16 Days of Activism against Gender-Based Violence Campaign is a time to galvanize action to end violence against women and girls around the world.

http://www.unwomen.org/en/what-we-do/ending-violence-against-women/ take-action/16-days-of-activism#sthash.zXvSzU8E.dpuf Sexual Violence:

¨ Rape ¨ Indecent Assault ¨ Forced Marriage

¨ Sexual Slavery http://www.eldis.org ¨ FGM (Female Genital Mutilation) ¨ Forced Pregnancy ¨ Forced Abortion ¨ Sexual Harassment

WHO: FGM

¨ „FGM comprises all procedures that involve altering or injuring the female genitalia for non medical reasons - , and is recognized internationally as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women and girls.“ Program 18 Nov 2016, 9-12 am ¨ Nomenklatur ¨ Klassifikation ¨ Global Prevalens ¨ Förklaringsmodeller ¨ Medicinska komplikationer ¨ Nationell & internationell Lagstiftning ¨ Vård i Sverige – AMEL-mottagning – Operativa rekonstruktioner – Desert Flower Scandinavia ¨ Global perspektiv – Internationella strategier (WHO och NGOs) – Medicalization of FGM

Terminology

¨ The expression ”Female Genital Mutilation" gained growing support from the late 1970s. The word ”mutilation” establishes a clear linguistic distinction from male circumcision, and emphasizes the gravity and harm of the act. ¨ In 1990, this term was adopted at the ”3rd Conference of the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children”, in Addis Ababa, Ethiopia. ¨ In 1991, WHO recommended that the United Nations adopt this term. It has subsequently been widely used in United Nations documents and elsewhere and is the term employed by WHO. Definition

¨ WHO: „all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons.“ Classification of the WHO (1)

¨ Type I: „Sunna“: excision of the prepuce, with or without excision of part or all of the clitoris Classification of the WHO (2)

¨ Type II: „Exzision“: excision of the clitoris with partial or total excision of the labia minora Classification of the WHO (3)

¨ Type III: „Infibulation“ („pharaonic circumcision“): excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening

Classification ot the WHO (4)

¨ Type IV: pricking, piercing or incision of the clitoris and/or labia; stretching of the clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue ♁ ♀

www.machimon.wordpress.com

Stephan G. Gilbert: Practical Human Embryology, 1989 ”… three man caught me, bundled me in to the toilet, pinned me down and undressed me. …I saw the knife and knew what was going to happen.” – young girl, Burkina Faso Statistics

(UNICEF, February 2016)

¨ Global: > 200 Mio. women and girls – ca. 80% Type II („Excision“) – ca. 15% Type III („Infibulation“) ¨ Incidens: + 3,6 Mio./year (Tendency ) = ca. 10.000/day = > 400/h

2014 www.unicef.org/media/files/FGM-C_Report_7_15_Final_LR.pdf

(GAMS – Belgique 2013) WHO

Spreading FGM type II & type III Humanitarian News and Analysis a service of the UN Office for the Coordination of Humanitarian Affairs

YEMEN: Eradicating FGM will be a slow process, experts say SANA, 14 November 2005 FGM is believed to be performed on approximately one quarter of all girls in Yemen

WHO (2008): prevalence 30% UNICEF (2013): 97% of FGM within the first month of a baby girl "Female Genital Mutilation in Iraqi Kurdistan"

Presentation to the conference:

1ère Journée Humanitaire sur la Santé des Femmes dans le Monde organized by Gynécologie sans Frontières

Paris May 8th 2006 By: Sandra Strobel and Thomas v. der Osten-Sacken, Wadi e. V.

www.stopfgmkurdistan.org

Iran: „About 50% among Sunni minorities“ http://www.stopfgmmideast.org/countries/iran (2015) United States Department of State: Indonesia: Report on Female Genital Mutilation (FGM) or Female Genital Cutting (FGC), 1 June 2001 ”… According to the study, of 100 mothers in the Kemayoran community in Jakarta, 97% of their female children had been circumcised. …”

available at: www.unhcr.org [accessed 10 February 2013] Total prevalence of FGM in Indonesia: 51%

www.data.unicef.org, february 2015 FGM in Western Countries Globale prevalence on FGM

(Source: Waris Dirie Foundation, Desert Flower)

Publications USA, middle of 20th century

¨ Female Circumcision, Indications and a New Technique W. G. Rathmann, MD Inglewood, California September, 1959 Dr. Rathmann writes: "The value of this procedure [female circumcision] in improving function has been recognized by various cultures for the past 3,500 years."

¨ Circumcision of the Female C. F. McDonald, MD Milwaukee, Wisconsin September, 1958 Dr. McDonald writes: "If the male needs circumcision for cleanliness and hygiene, why not the female?" 1958

UNICEF (2015): Why is FGM practiced / background

¨ Tradition (Egypt ca. 2500 A.C.), initiation rites ¨ Religion (known in all religions) ¨ Cultural reasons linked to the place of the women in society ¨ Medical and health reasons ¨ Aesthetics ¨ Hygiene ¨ Money, Power, Prestige ¨ Female discrimination ¨ Suppression of the female sexuality

On the sarcophagus of Sit-hedj-hotep, who lived sometime during the 12th dynasty of the middle kingdom (1991-1786 B.C.E.), there is a ritualistic procedure written down which describes circumcision involved in some sort of magical act

(source:GenderEgyptANT3145-fall11BrittanniWyatt)

Why is FGM practiced / background

Lit: Toubia, N. (1993): Female Genital Mutilation: A Call for Global Action. New York: Women, Ink; pp. 21. Demographic and Health Survey - Egypt. (1995). Calverton, MD: Macro International Inc. pp. 173. http://www.path.org ”When you cut a girl, you know she will remain pure until she gets married, and after marriage, she will be faithful. …But when you leave a girl uncut, she sleeps with any man in community.” – female circumcisor, Kenya FGM Performing: Who and how? ¨ Crude instruments: Knifes, scissors, glassfragments, razor-blades etc. ¨ Stitching with all kind of threads, thorns, horsehair, metalrings. ¨ Anaesthesia: no ¨ Dressing: unsteril, everything you find ¨ Usually performed by women (midwives, traditional healer, local practitioner) ¨ Age: usually 4-10 years older (Tendency ) ¨ Mostly in the rural areas, low education Female genital mutilation Fact sheet N°241

February 2010 updated February 2016

“… FGM has no health benefits, and it harms girls and women in many ways. It involves removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls' and women's bodies … violation of the human rights of girls and women. “

16 May 2016 May 2016 November 2016 – Volume 128 - Issue 5 – p 958–963

Female Genital Mutilation: A Visual Reference and Learning Tool for Health Care Professionals Abdulcadir, Jasmine MD; Catania, Lucrezia MD; Hindin, Michelle Jane PhD; Say, Lale MD; Petignat, Patrick MD; Abdulcadir, Omar MD

¨ „ …The tool can be consulted by caregivers when unsure on the type of female genital mutilation diagnosed and used for training and surveys for monitoring the prevalence of female genital mutilation types and subtypes.“

http://journals.lww.com/greenjournal/Citation/2016/11000/Female_Genital_Mutilation__A_Visual_Reference_and.4.aspx Health consequences (1) immediate:

¨ Acute psycho trauma ¨ Severe pain ¨ Infection – Localinfection – Abscess formation – General infection – Septic shock – HIV-infection – Tetanic – Gangrene ¨ Problems with urine – Urine retention, edema of the urethra, dysuri ¨ Injury – of the neighbouring organes (i.e. bladder) – Fractures (femur, claviculae, humerus) ¨ Bleading – Haemorrhage, anemia, shock ¨ Mortality because of acute complications: ca. 10%

Photographies from publications 1920 ff. Health consequences (2) chronic diseases:

¨ Mortality because of long term complications (ca. 25%) ¨ Sexuality / menstruational bleeding – Dyspareuny/Apareuny, painful intercourse – Vaginal stenosis – Infertility – Dysmenorrhoea – Menorrhage – Chronic vaginitis, endometritis, adnexitis ¨ Problems with urine – Chronical urinary tract infections – Urinary tract obstruction – Incontinence ¨ Complications with the scar – Failure to heal – Abscessformation – Keloids, Dermoid cyst – Scar neuroma – Hämatokolpos – Pseudo infibulations A large sebaceous cyst after circumcision (© www.vulvovaginaldisorders.com)

Complications with the scar

Keloid Haematocolpos Complications of labour and delivery

– Painful vaginal examination – Impossible to put in a catheter – Fetal blodcheck (pH) impossible – Second stage prolonged – Perineal injuries – Postpartum haemorrhage – Perineal infections – Vesico-/rectovaginal fistula

– Perinatal mortality increased by 30% (WHO, 2006) !loysius Osagie: „Infibulation Stone“ Delivery ¨ ”The Obstetric Consequences of Female Genital Mutilation/Cutting: A Systematic review and Meta-Analysis” ¨ Rigmor C Berg, Vigidis Underland 2013 ¨ 44 studier, > 3 mio. Patients

¨ Increased risk: ¨ prolonged labor ¨ obstetric lacerations ¨ instrumental delivery ¨ obstetric hemorrhage ¨ difficult delivery ¨ not for cesarean section and episiotomy Consequences of FGM (3) Psycho social injuries

¨ Traumatising, PTSD ¨ Behaviour disorders ¨ Lack of confidence ¨ Anxiety, depression ¨ Frigidity ¨ Psychological effects ¨ Conflicts with the partner FGM and the law

• National law (most countries) – Sweden: specific law against FGM (1982): « Förbud mot könsstympande ingrepp » Laget skärptes 1999: « En person kan dömas i Sverige for brott mot laget även om brottet begåtts utomlands. » Preskriptionstid 15 år, lagändring föreslås: från och med 18 år • International Law – Human Rights, Right to Health (1948) – UN General Assembly: Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW) (1979/1990) – The Right to Life and Physical Integrity (1989) – International convention on Children's Rights (1989) – Convention of Women's Rights (1994) – Antidiscrimination convention (1999) • African Charta (1990) • African Protocol on Rights of Women (2005) Anmälningsskyldighet: Barn och ungdom (< 18 år)

¨ Personal inom verksamhet som berör barn och ungdom är skyldiga att genast anmäla till socialtjänsten om de i sin verksamhet får kännedom om något som kan innebära att socialnämnden behöver ingripa till ett barns skydd. ¨ Även polisanmälan kan vara aktuell. Om enbart polisanmälan gjorts, måste polis och åklagare beakta sin skyldighet att anmäla misstankar till Socialtjänsten enligt 14 kap 1§ Socialtjänstlagen (SoL). Publicerad 26 juni 2006

” ... Göteborgs tingsrätt dömde en 41-årig man till fyra års fängelse för att han låtit könsstympa sin dotter i Somalia. Pappan ska också betala skadestånd, 300.000 kr. Det är första domen i Sverige fastän lagen funnits sedan 1982. ...” FGM and the law

2013 Al-Azhar University Sheikh Ali Gomaa

”Egyptian Clerics Say Female Circumcision Un-Islamic”

”Excision is a practice totally banned by Islam because of the compelling evidence of the extensive damage it causes to women's bodies and minds." in: ”Women Health News” (www.medindia.net) July 04, 2007

”Grand Mufti of Egypt Ali Gomaa denounces female circumcision and calls the practice a punishable offense following an international Islamic conference of scholars”

in: ”Circumcision for Females” (www.islamopediaonline.org) April 22, 2010

Care i industrial countries / west

¨ Medical Care ¨ Psychosocial Care ¨ Prevention for the next generation, daughters of the immigrants

¨ Support of local groups ¨ Raising awareness ¨ Lobbying

Läget i Sverige ¨ De största grupperna i Sverige, som kommer från länder där sedvänjan praktiseras, är från Somalia, Eritrea, Etiopien, Egypten och Gambia ¨ I Sverige finns ca 38.000 kvinnor som är födda i ovanstående länder eller som har minst en föräldrer som kommer därifrån. Ca 7.000 av dessa kvinnor är under 18 år. Dessa flickor och kvinnor har genomgått könsstympning innan de kom till Sverige (SCB, 2015). ¨ Riskgruppen (flickor med en moder som är född i ett land där könsstympning är vanligt förekommande, risk för att bli utsatta för könsstympning ) ca 19.000 (SCB, 2015). FGM: Prevalens/capita

Land Population Total FGM / 100 000

Sweden 9.7 m 38.000 390 Norway 5.1 m 17.500 343 UK 60.8 m 120.000 197 France 66.6 m 65.000 97 Germany 80.7 m 60.000 74 USA 320.2 m 120.000 37 Kvinnlig könsstympning och kontakten med den svenska sjukvården: En studie av reaktioner och erfarenheter hos svensk sjukvårdspersonal i kontakt med kvinnlig könsstympning 1994 Söder, C. & Hamring, S. IPIK (Institute of Psychotherapy and Intercultural Communication) Study financed by Folkhälsoinsitutet ¨ Hälso- och sjukvårdspersonal s. 54-68 Kvinnlig – Medicinsk vård och könsstympning kulturkompetens – Förebyggande arbete – Kvinnans partner – Gynekologisk undersökning av Ett utbildningsmaterial för könsstympad kvinna skola, socialtjänst och – Mödrahälsovård hälso- och sjukvård – Rutiner vid förlossning – Uppföljning och eftervård Juni 2005 – Barnhälsovård – Skolhälsovård – Ungdomsmottagning – Övriga mottagningar http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/9960/2005-110-4_20051104.pdf ¨ Fokusrapport: Mötet med könsstympade kvinnor i vården. Medicinskt programarbete, SLL

2007 2008

…..

…. Boken vänder sig främst till yrkesverksamma och studenter inom bland annat vård- och omsorg, socialtjänst, skola och polismyndighet. … ¨ Socialstyrelsen – Webbutbildning

http://www.socialstyrelsen.se/publikationer2015/2015-2-4

¨ “Våga se” – En vägledning för stöd, vård och skydd av flickor och kvinnor som är eller riskerar att bli könsstympade

2015 Juni 2016 FGM Kvinnlig könsstympning & sjukvården

https://unicef.se/fakta/kvinnlig-konsstympning Medical treatment for the patients (se also recommendations of FIDE, workinggroup of DGGG = Frauengesundheit in der Entwicklungszusammenarbeit)

¨ Carefull in communication / (female) translator ¨ Sensibility in vaginal examinations ¨ Treatment of infections ¨ Correction of anatomical urine and menstruational complications ¨ Removing of the Infibulation (Defibulation) with anaesthesia if patient desires before or during delivery

¨ Start 2003 ¨ Ca 100 nybesök/år ¨ 5 Gynekologer + 1 kurator ¨ På gynmottagning, flera tider/vecka ¨ Ej remisstvång ¨ Kvinnlig tolk ¨ Pat i fertil ålder (median 25 år, yngsta 13 år)

somalia

¨ Ursprung eritrea

övriga ¨ Tel: 08 – 616 2700

AMEL-mottagningen (”hopp” på arabiska )

¨ AMEL-mottagningen tar emot kvinnor med problem orsakade av könsstympning. Du behöver ingen remiss för att komma till oss och du hittar mottagningen i gynekologmottagningens lokaler. Vid språksvårigheter använder vi oss alltid av en kvinnlig tolk, ofta med hjälp av högtalartelefon. ¨ Du kan vända dig till mottagningen med både kroppsliga och psykiska problem. Kroppsligt kan problemen bestå av allt från oförmåga att ha samlag till svåra bäckenbottenskador efter förlossningar och vattenkastningsbesvär. Till de psykiska problemen hör både sexuella problem, tillitsproblem och svårare psykiska problem som har orsakats av könsstympningen. ¨ På mottagningen lägger vi stor vikt vid insikter i traditionens bakgrund. Detta i kombination med våra medicinska kunskaper gör att vi kan tillgodose de speciella behov som finns och ge könsstympade kvinnor den vård de behöver. ¨ Hos oss på mottagningen arbetar fem gynekologer och en kurator. AMEL-mottagningen: Våningsplan: 0 Hiss: B Ingång: Huvudentrén

Amel-mottagningen Pat söker för

¨ Sena komplikationer (WHO) – Problem med sexualitet / menstruation blödning – Problem med urin (inkontinens, UVI) – Komplikationer med ärret, neurinom ¨ Intyg ¨ Oförmåga att genomgå cellprovskontroll ¨ ”hur ser jag ut?”

¨ Rädsla för gynundersökning Fysiska besvär ¨ Våldtäkt Psykiska problem Social problem Migration process Amel-mottagningen: Att tänka på

¨ Patient befarar vår okunskap/reaktion ¨ Skapa trygghet ¨ Tillkalla kollega? ¨ Forcera inte! ¨ Utgå från symptom ¨ Våga fråga! ¨ Säg “omskärelse” ¨ Varsamhet/respekt ¨ Informera om normal anatomi ¨ Visa med spegel om hon vill, rita.

Amel-mottagningen Vad gör vi ? ¨ Skriver intyg ¨ Gynekologiska undersökningar ¨ Medicinska utredningar ¨ Sexual undervisning ¨ Ger stödsamtal, kurator ¨ Operativa åtgärder – Defibuleringsoperation (”õppnar”) – Tar bort cystor – Korrigerar förlossningsskador – Kooperation med Plastisk Kirurgi på Karolinska Sjukhus Förlossning av könsstympade kvinnor

¨ Vid ankomst till förlossningen ¨ Defibulering ¨ Perineotomi ¨ Suturering Observera att det enligt lag är förbjudet att reinfibulera (åter sy samman labiae), även om kvinnan så skulle önska. ¨ Efter förlossningen

Fokusrapport: Mötet med könsstympade kvinnor i vården. Medicinskt programarbete, SLL 2007. Essen B et al: Are some perinatal deaths in immigrant groups linked to suboptimal perinatal care services? BJOG 2002. PM på Kvinnokliniken Mälarsjukhuset

Handläggning av könsstympade kvinnor inom

– Mödrahälsovården Deinfibulation-kvinnlig – Förlossning könsstympning – Gynekologisk uretra undersökning – Vid Defibulerings operation

2005-10-20 50 Operational procedure: Defibulation Defibulation to treat female genital cutting: effect on symptoms and sexual function. Obstet Gynecol. 2006 Jul;108(1):55-60

Nour NM, Michels KB, Bryant AE. ¨ … to evaluate the long-term health and sexual satisfaction … ¨ 94% would highly recommend it to others. 100% of patients and their husbands were satisfied with the results, felt their appearance had improved, and were sexually satisfied.

“In conclusion, defibulation is recommended for all infibulated women who experience long-term complications such as dysmenorrhea, dyspareunia, apareunia, or chronic vaginal and urinary infections.”

The American College of Obstetricians and Gynecologists Surgical techniques (1)

J Sex Med 2007; 4: 1544-1547 (2)

Nour NM et al.: J Sex Med 2007; 4: 1544-1547 (3)

Nour NM et al.: J Sex Med 2007; 4: 1544-1547 (4)

Nour NM et al.: J Sex Med 2007; 4: 1544-1547 (5)

Nour NM et al.: J Sex Med 2007; 4: 1544-1547 Amel-mottagningen: Defibulation Amel-mottagningen: Removing of a cyst and defibulation Pierre Foldès (Centre Hospitalier de Saint-Germain en Laye, France)

Prog Urol. 2004 Feb;14(1):47-50. ¨ Reconstructive plastic surgery of the clitoris after sexual mutilation. ¨ „ ... clitoris reconstruction technique after ritual excision. After resection of the scar, the angle and the body of the clitoris are then released by preserving the innervation. A clitoral glans is reconstituted by wedge plasty, then reimplanted in an anatomical position. This technique is designed to restore normal anatomy and obtain a normally innervated and whenever possible functional organ.“ a. Normal anatomy b. A non-mutilated clitoris c. Fixed clitoris after scarring d. Type II mutilation e. Schematic outcome after reconstructive surgery f. Outcome after 1 year Sexual and reproductive health

(WHO 2014)

Female genital mutilation and other harmful practices Treatment of persons with female genital mutilation Surgical repair after excision of the clitoris

¨ References: Foldes P, Louis-Sylvestre C.: Résultats de la réparation chirurgicale du clitoris après mutilation sexuelle: 453 cas (Results of surgical clitoral repair after ritual excision: 453 cases). Gynécologie, Obstétrique & Fertilité 2006; 34:1137-1141.

Volume 380, Issue 9837, Pages 134 - 141, 14 July 2012

Reconstructive surgery after female genital mutilation: a prospective cohort study

Pierre Foldès, Béatrice Cuzin, Armelle Andro

¨ We operated on 2938 women with a mean age of 29,2. Mali, Senegal, and Ivory Coast were the main countries of origin, but 564 patients had undergone female genital mutilation in France. ¨ The 1-year follow-up visit … 866 patients (29%) Most patients reported an improvement, or at least no worsening, in pain (821 of 840 patients) and clitoral pleasure (815 of 834 patients). … 430 (51%) of 841 women experienced orgasms. Immediate complications after surgery (haematoma, suture failure, moderate fever) were noted in 155 (5%) of the 2938 patients, and 108 (4%) were briefly re-admitted to hospital. ¨ Reconstructive surgery after female genital mutilation seems to be associated with reduced pain and restored pleasure. It needs to be made more readily available in developed countries by training surgeons. J Sex Med. 2015 Jan

Conclusion “… positive outcome in pain reduction and improved sexual function, self body image, and gender after psychosexual therapy and clitoral reconstruction. More evidence is needed about clitoral reconstruction to develop guidelines on best practices. … always offering a multidisciplinary care, including sexual therapy before and after the surgery.”

Ann Chir Plast Esthet. 2013 Jun; 58(3):208-15. Practice of reconstructive plastic surgery of the clitoris after genital mutilation in Burkina Faso. Report of 94 cases

Ouédraogo CM, Madzou S, Touré B, Ouédraogo A, Ouédraogo S, Lankoandé J

¨ A retrospective study 2007 - 2010. ¨ … Evaluation 6 months after surgery ¨ … restoration of the clitoris at 89.7 %. … . A significant improvement in sexuality was observed in 83.6 % of patients. However, there was no significant difference between orgasm before and after surgery. This showed us that getting an orgasm is multifactorial and it is not enough to have a clitoris to have an orgasm, you have to use it. Cooperation: SÖS (Amelmottagning) and KS (Kliniken för Rekonstruktiv Plastikkirurgi) Multidisciplinary approach: ¨ Gynecologist ¨ Reconstructive plastic surgeon ¨ Urologist ¨ Midwife ¨ Psychotherapist ¨ Sexologist ¨ Social worker Cooperation: SÖS (Amelmottagning) and KS (Kliniken för Rekonstruktiv Plastikkirurgi) Defibulation and Clitoris Reconstruction Labia reconstruction

Gynecol Oncol. 2010 Dec;119(3):526-30. ¨ The anterior Obturator Artery Perforator (aOAP) flap: surgical anatomy and application of a method for vulvar reconstruction. O'Dey DM, Bozkurt A, Pallua N.

44. Jahrestagung der Deutschen Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen e. V. (DGPRÄC), 12.09. - 14.09.2013, Münster ¨ Der Omega-Domed flap (OD-Lappenplastik): eine neue Operationstechnik zur Rekonstruktion der Regio clitoridis nach ritualer Genitalverstümmelung (FGM – Female Genital Mutilation) O'Dey DM, Pallua N

Labiaplasty

Why would I want labiaplasty surgery? ¨ Discomfort and Esthetics ¨ Cosmetic Reasons: Women who are unhappy or embarrassed with the way their labia look. Often this affects sexual relationships and self-esteem. Some women just want to look as beautiful as they can for themselves and their partner. With the increasing openness of society to sexuality and greater exposure to sexually explicit materials, labiaplasty is becoming increasingly popular.

Opened: 17th Nov 2016

http://manhattancenterforvaginalsurgery.com/labiaplasty-procedure/ Opend: 17th Nov 2016

¨ „Labiaplasty (also called labial rejuvenation, labia reduction, or labioplasty) is a procedure which recontours or reduces the size of the labia minora. Enlarged or uneven labia minora can occur naturally with hormonal changes, or after stretching from multiple childbirths or sexual intercourse. This can cause difficulty with hygiene, irritation, and discomfort. Women who visit us for labia reduction in Sarasota often complain of discomfort while performing activities like biking, jogging, or sexual intercourse. ¨ Fortunately, with a simple outpatient procedure women can regain their confidence and reduce their discomfort. …“

Labia Minora Reduction, Labiaplasty, Vagina Rejuvenation, Vaginoplasty by Dr. Daniel Medalie …He also performs clitoral hood reduction and fat injection to the labia majora. …

Opened: 17th Nov 2016

http://www.clevelandplasticsurgery.com/procedures/labiaplasty-vaginoplasty Search Results Labiaplasty Sweden - Check Prices and Compare Reviews

¨ Stockholm Labiaplasty

¨ Labia reduction, re-shaping outer and inner lips ¨ Labiaplasty is one of the three major areas of cosmetic vaginal surgeries. The procedure aims to correct dysfunctions and improve the woman`s hidden aesthetics. ¨ The way a woman feels about the look and sensation in her vagina and pubic areas has a major impact on her self-esteem, her sexual desire, and her intimate relationship. ¨ There are three major areas of Cosmetic Vaginal Surgeries, aimed to rejuvenate a woman’s sexual feeling: ¨ Labia surgery (labiaplasty, labia reduction and look improvement, correcting the size and shape of the inner and outer lips) ¨ Vaginal reconstruction and rejuvenation (vaginoplasty, mainly vaginal tightening) ¨ Hymenoplasty (hymen reconstruction, “bringing back to virginity”)

¨ Since 2002, founded in Vienna, Austria ¨ Lobbying, global campaigns, initiatives in Africa ¨ 11.09.2013: 1st Desert Flower Center in Berlin ¨ 2015 Desert Flower Scandinavia International Perspective

2008 Strategies for combating FGM: (see also WHO, UNICEF, Terre des femmes etc.) ¨ Creating of legal conditions ¨ Solidarity with these women ¨ Health education ¨ Education of practitioners ¨ Integrated social approach ¨ Alternative Initiation rites ¨ Sociale programs, national strategies ¨ Cooperation with the national health system and with autorities

Practical Steps against FGM

¨ 1979 public protest in Khartum/Sudan against this cruell tradition ¨ 1984 Inter-African Committee (IAC) against FGM (supported by the WHO and UNICEF) ¨ 1994 CNLPE (Comité National de Lutte contre la Pratique de l‘Excision) in Burkina Faso: education, training of multipliers, cooperation with other NGO‘s and with the church ¨ Project activities of Terres des Femmes ¨ etc

Female Genital Mutilation video

Clitoraid

FGM in Kenya Female Genital Mutilation

Female Genital Cutting

Horror of female Circumcision

Scott Campbell hearts Mom etc Director: Nancy Durrell McKenna & John Howarth Producer: Nancy Durrell McKenna Writer: John Howarth Genre: Documentary Country: United Kington Duration: 47 minutes Original Format: PAL DVD Photography: John Howarth Art Direction: John Howarth Editing: John Howarth Education Mali

UNICEF + Sini Sanuma Côte d‘Ivoire

Kenya

Egypt

Ethiopia

Iraq

UNICEF + Wadi Sweden

Könsstympning av flickor och kvinnor – en informationsfilm

Khadra Seerar

Publicerades 2016

http://www.hedersfortryck.se/hedersfortryck/informationskampanjer/ informationsfilmer/informationsfilm-konsstympning-till-yrkesverksamma/ 2016-02-05

Khadra Seerar: ”Jag kallar mig överlevare” ¨ Det viktigaste är att bryta tabut mot könsstympning, säger Khadra Seerar. Hon berättar om sina erfarenheter för att hålla frågan aktuell.

http://www.dn.se/insidan/khadra-seerar-jag-kallar-mig-overlevare Breaking inhuman traditions

Road sign near Kapchorwa, Uganda, 2004

Road sign in Bakau, Gambia, 2005

(2004)

1923-2007 Empathy and Rage: Female Genital Mutilation in African Literature

Co-Edited by Tobe Levin and Augustine H. Asaah Empathy and Rage - these words bracket a spectrum of feelings people confront when they think about the millions of women and girls who have undergone bolokoli, takhoundi, tukore, or gudni’in - names in local languages for a procedure that mutilates women’s private parts or Female Genital Mutilation (FGM). May 22, 2009 Local/regional organisations Examples:

NAFGEM (Tanzania): – Network Against Female Genital Mutilation – Founded 1997 – Changing the attitude / creating sensibility – House-to-house-councelling, grass-root-work, theatre, education, qualification-programs for „cutters“, TV/broadcasting, including higher political levels in the activities, network with other partner-NGO‘s and with the churches, etc.

¨ Established in 1998 by a group of doctors in Nigeria ¨ Health education instead of activism – Men as a special target group ¨ Alternate career for professional cutters ¨ Support to girls who escape mutilation ¨ Activities in western countries – Lobby work, improve legal situation – Work with immigrant communities ¨ Supporting free medical treatment – Care on acute/chronic complications – Obstetric fistula surgery – Clitoral reconstructive surgery

¨ Campaign Against Female Genital Mutilation (CAGeM) will help make the surgery available in Africa too. ¨ CAGeM is building a hospital in Port Harcourt, in southern Nigeria. The so called Restoration Hospital will provide the surgery for free and be open to any patient from West Africa. ¨ Dr. Aberie Ikinko, director of the organization’s US branch, explains: “We have already 400 women on the waiting list. We are also training the local doctors so that when we leave, they can continue to perform the surgeries for free.”

http://www.un.org/africarenewal/magazine/january-2013/reconstructive-surgery-brings-hope survivors-genital-cutting#sthash.eUUAxmTt.dpuf ¨ TOSTAN (Senegal): – Theatre, role-playing and other hands-on methods in local language – Including community leaders, imams – Named by WHO and UNICEF as model program ¨ Naserian Women Group (Kenya): – Income-generating projects to strengthen the decision-making status of the women by economic power WHO response

In 2008, the World Health Assembly passed a resolution (WHA61.16) on the elimination of FGM, emphasizing the need for concerted action in all sectors – health, education, finance, justice and women's affairs.

Focus on Advocacy, research, guidance for health systems

WHO is particularly concerned about the increasing trend for medically trained personnel to perform FGM. WHO strongly urges health professionals not to perform such procedures.

Medicalization of FGM

(BBC News Health 21 July 2014) African Journal of Urology Volume 19, Issue 3, September 2013, Pages 145–149 Female genital cutting/mutilation in Africa

In some countries FGM/C is increasingly performed by health-care providers, which is alarming. Medicalization of FGM/C is proposed by some health professionals to reduce the incidence of its complications. However medicalization of FGM/C will not reduce the long term complications of FGM, has no benefit what so ever, has no medical indication, and thus its performance violates the code of medical ethics. Furthermore its medicalization would result in a setback in the global efforts to eradicate this harmful practice, and will give the green light to its performance by non health-care providers with subsequent increased incidence of complications. FGM/C

closely with the World Health Organization

(WHO) on an interregional initiative in sub-

„Medicalization: a threat to abandonment“

„ …. To adress this alarming trend, in 2009, the Joined Programme began working closely with the World Health Organization (WHO) on an interregional initiative in sub- Saharan Africa and Arab nations to ensure that the medical profession openly supports the abandonment of FGM/C …“

2014

that the medical profession openly supports

the abandonment of FGM/C.

CounteringWith support from the the medicalizationJoint Programm of Lancet; Vol 369; March 31, 2007 ¨ „Africa battles to make female genital mutilation history: During the past 2 years, substantial progress has been made in changing attitudes towards female genital mutilation in countries such as Guinea, Egypt, Tanzania, Kenya and Senegal. But the practice remains widespread across Africa.“ „…only little progress in countries like Gambia or Cameroon.“ „… totally failled in others such as Somalia.“ Lancet; Vol 369; March 31, 2007

¨ „ … Poor education and low level of income among women in African countries, coupled with inadequate governmental support in efforts to eradicate the practice, mean it will take longer to stamp out. …“

Thank you for your attention

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