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Home , Cervix, Infibulation, Nine Parts of Desire

Female Genital Mutilation: Perspectives, Risks, and C o m p l i c a t i o n s

Rita I. Morris

Female genital mutilation, traditionally known as female circ u m- emale genital mutila- cision, is a surgically unnecessary modification of the female geni- tion (FGM), traditional- talia, practiced in nations in Africa, the Arab Peninsula, among some ly known as female cir- communities in Asia, and among immigrants and refugees fro m cumcision (FC), is a these areas who have settled in other areas. The practice is known Fs u rgically unnecessary modifica- a c ross socio-economic classes and among many diff e rent ethnic and tion of the female genitalia, cultural groups, including Christians, , Jews, and followers of practiced in 28 nations in the indigenous African religions. As people from these areas immigrate African continent, in a few to North America, health care professionals need to understand the countries in the Arab Peninsula, important aspects of this growing problem, including management among some communities in of complications, cultural attitudes, and sensitivities. Asia, and among immigrants and refugees from these are a s who have settled in Euro p e , Australia, and North America. cy or until the girl is of mar- ra. The raw surfaces of the two The practice is known acro s s riageable age, approximately 14 sides of the are then socio-economic classes and to 16 years old; most common- s u t u red together obliterating the among many diff e ren t ethnic ly, between ages 4 to 12 years. i n t r oitus. A very small opening and cultural groups, including Type 1: (Sunna). C i r c u m- is left to allow for the flow of Christians, Muslims, Jews, and cision proper is excision of the urine and . Fifteen followers of indigenous African clitoral prepuce only. Clitori- p e rcent of all women who religions (Toubia, 1994). dectomy: part or the whole of experience female circ u m c i s i o n the is amputated and the have this type. re p- Types of FGM/FC bleeding is stopped with pre s - resents 80%-90% of all female T h e re are four major types s u r e or with stitches. c i r cumcision in , , of female circumcision prac- Type 2: Excision (Inter - and . ticed, three of which are most m e d i a t e ) . Involves the re m o v a l Type 4: Rare types of FGM or commonly practiced. FGM is of prepuce and glans clitoris m a n i p u l a t i o n . Gishiri cuts are the collective name given to together with the adjacent parts vaginal cuts made during labor several diff e r ent traditional of the minora. Bleeding is to relieve obstructed labor and practices that involve the cutting usually stopped with stitching, practiced only in Nigeria. In of female genitals. It is a tradi- but the is not covere d . some communities the clitoris is tional ritual that pre p a r es girls Eighty-five percent of all not cut, but burned with a hot for their social roles as women. women who undergo female stone, pricked to let blood, or It is practiced as early as infan- c i r cumcision have either Type 1 washed with chemicals or or Type 2. herbs. In other communities no Type 3: Infibulation (Phar - cutting is employed but the onic circumcision). The entire labia minoria are stretched fro m clitoris is removed together with a very young age in the belief Rita I. M o r r i s , P h D, R N , is an Associate Professor and Chair, adjacent parts of the labia mino- that large labia enhance sexual C o m munity Health Nursing, San Diego ra and the adjacent medial por- p l e a s u re. Entrocision is another State Unive r s i t y, San Diego, CA. tions of the interior labia majo- f o rm of cutting into the vagina

UROLOGIC NURSING / March 1999 / Volume 19 Number 1 13 reported among some sade had a charismatic leader in Ismalili Shia sect, adopted Islam Aborigines in Australia at the Fran Hosken who since 1973 f rom and practice FGM. t u rn of the century. has taken up this issue, lobby- Other Muslim groups in India ing the World Health do not practice FGM. In Historical Perspectives of O r ganization and numero u s Pakistan, only the Bohra tribe F G M other international agencies. practice (To u b i a , Historically, mutilations She has written extensively on 1 9 9 5 ) . have been carried out on this issue and is credited for Indonesia had genital cut- infants, girls, and women, com- compiling much of what is ting operations in the past, but monly between 4 and 12 years known about the epidemiology a re no longer perf o rmed. A of age. Women who are excised of FGM around the world (Lane series of ritual clitoral cere- at a very young age do not & Rubinstein, 1996). monies persist, which include question the pro c e d u re and In the mid 1980s and ‘90s cleaning and applying sub- g r ow up not knowing any other many refugees from African stances around the clitoris, sym- way of being (Goodwin, 1994). countries brought with them a bolic cutting, or light puncture Health care professionals need s e c ret ive and little known pro b - of the clitoris. These practices to learn a great deal more than lem — female genital mutila- a re not considered genital muti- we know today about the ori- tion. This practice was con- lation (Toubia, 1995). gins of female mutilation. It is demned widely in the We s t e rn Jones (1997) identified the not possible to conclude popular and scholarly pre s s e s population at risk in the United whether there was one origin or and has led to legislation pro- States. The findings, adjusted to several independent origins. hibiting the continuance of this the total U.S. population, esti- Female slaves in ancient Rome practice in many countries. mated 271,000 females living in had one or more rings put the U.S. in 1990 who re p o r t e d t h r ough their to Estimates of Wo m e n ancestry or place of as a p r event their becoming pre g- with/or at Risk of FGM/FC country or region where FGM is nant. Chastity belts were Globally, FGM prevalence is practiced. About one-fourth b rought to Europe by the estimated at 130 million girls (77,000) females were girls Crusaders. Some scholars posit and women. The World Health under 18 years of age. Eleven that infibulation was practiced O r ganization, which urges the m e t ropolitan areas have an esti- in ancient Egypt and perh a p s elimination of the practice, esti- mated 45% of women and 44% originated there or perhaps in mates that 2 million girls under- girls under age of 18 years who Africa as a rite and go FGM each year (Bureau of a re circumcised or are at risk. In came to Egypt by diffusion. It is Refugee Programs, 1992). all, 65% of the estimated num- generally agreed that the prac- C u r r ently, it exists in at least 28 ber of girls under 18, with or tice was widespread in the pre - African countries, some minori- potentially at risk for FGM/FC, Islamic era in Egypt, Arabia, and ties in Asia, and refugee immi- live in 35 metropolitan areas in on the Red Sea coasts (The grants in Europe, Australia, and the ; about 72% of Minority Rights Group, 1985). North America. It should be these girls were born in the The practice of female cir- noted that the distribution with- United States. cumcision is widespread in all in a country is not uniform and Since 1990, Immigration and continents of the world. A is determined by tribal and eth- Naturalization Service (INS) data G r eek papyrus dated 163 B.C. nic divisions. Clitoridectomy is show the country of origin for made specific re f e r ence to the most common pro c e d u re by over 121,000 immigrants admit- female circumcision. Va r i o u s f a r. Infibulation predominates in ted between 1991 and 1995 to authors have documented the Somalia, Djibouti, and Northern the United States was a country practice as existing as early as Sudan, as well as in Southern in Africa where FGM/FC is prac- the 5th century B.C. originating Egypt and the coastal areas of ticed. Immigrants from Somalia in or Egypt. Early Ethiopia. Outside Africa it is and Sudan, countries most Romans and Arabs also adopted seen in Oman, South Ye m e n , a f fected by FGM/FC, show the practice as a mark of . marked increases of immigrants enslavement and subjugation. In Asia, clitoridectomy is to the United States. The worldwide debate on practiced in India and Pakistan the custom began in the 1970s by a small ethno-re l i g i o u s Factors that Encourage prior to which FGM was studied minority with a total population the Practice of FGM/FC in the context of cultural re l a- of a half a million. In We s t e rn The ritualization of female tivism. The antimutilation cru- India, the Daudi Bohra of c i r cumcision is strongly embed-

14 UROLOGIC NURSING / March 1999 / Volume 19 Number 1 ded in the belief that women of status for women and cir- Economic benefits. T h e a re highly sexed and by nature cumcision is a pre requisite for father gets paid the bride price. p r omiscuous. Infibulation, which marriage. Infibulation ensure s The evidence of virginity is seals off the vagina, serves to the girl’s virginity, upholds the infibulation. In areas where cir- isolate the woman against her family honor, and secures a cumcision is the norm, uncir- own sexual desires and the sex- high bride price (Van der cumcised girls will not find hus- ual aggression of others Kwaak, 1992). bands. It is thought to impro v e (Schwartz, 1994). Distinguishes the chaste fertility and prevent matern a l Religious influences. S t ro n g f r om the adultero u s . In many of and infant mortality. justification for continuing FGM the societies where female cir- Maintains good health. It is lies in the belief that Allah cumcision is the norm, poly- believed that circ u m c i s e d re q u i res the pro c e d u re. gamy is practiced. However, a women are always healthy and (1995) reported that re l i g i o u s woman can only have one hus- never complain of physical ail- justification is the dominant re a- band; hence, her virginity is ments, except those bro u g h t son given for continuing the p r otected, promiscuity pre v e n t- about by supernatural causes. practice. Among Muslim com- ed, and uncontrollable sexual Female circumcision, it is munities, it is not uncommon to demands on their husbands lim- believed, cures women who find that female excision has ited through circ u m c i s i o n . s u ffer from , melan- been traditionally practiced Dampens sexual desire and cholia, nymphomania, hysteria, under the adherence to re l i- vulnerability to sexual tempta - insanity, and epilepsy. gious principles. However, the t i o n . It is believed that if the cli- Koran does not mention female toris is left intact, it will gro w Rationale for Disfavoring c i r c u m c i s i o n . and increase a woman’s desire the Practice Beauty and cleanliness. to have sex; hence, its re m o v a l Traditional/cultural prac - Hygienic and aesthetic re a s o n s subdues a woman’s response. It t i c e . A past traditional and cul- a re featured in the belief system is also believed that tural practice, even though con- with the misconception that could contaminate a nursing s i d e red a right of passage, is female genitalia are unclean and mother’s milk and harm the viewed as barbaric as it re s u l t s ugly (Calder, Brown, & Rae, baby. There f o r e, for the 18- in deform i t y . 1993). The removal of the exter- month breastfeeding period, the Unnecessary pro c e d u r e . nal genitalia is recommended in mother abstains from all sexual Absolutely unnecessary pro c e - order to make the woman more relations. The sexless life is d u re causing severe pain and sexually attractive. m o r e tolerable to the circ u m- lifelong suffering for women. It is believed that secre t i o n s cised woman. Marriage complications. p r oduced by the glands in the E n s u r es fidelity in a mar - C i rcumcision causes complica- clitoris, and majora r i a g e . Reinfibulation after child- tions during marriage. Wo m e n a re foul-smelling and unhygien- birth is a means to ensure that a re unable to enjoy their wed- ic and thus make the female the woman remains faithful. ding night and approach their body unclean. Since the The male has no curbs to his husbands filled with dread and woman’s role is the pre p a r a t i o n sexual desires as he is perm i t t e d f e a r. The marriage experience of food, removal of the body to have many wives. leaves many women with hate parts producing the unclean- P r omotes social and politi - for their husbands. ness is considered appro p r i a t e . cal cohesion. C i r cumcision is Labor complications. Wo- I m p r ovement of male sexual the ritual which completes the men with FGM often have diff i - p e r f o r mance and pleasure . It is acceptability and bonding cult labor and delivery re s u l t i n g believed that the clitoris gener- p r ocess among females. Wi t h- in many complications. ates additional excitement for out this pro c e d u re, there is no P s y c h o s e x u a l . C i rc u m c i s i o n the male leading to early ejacu- life, community, or kin. FGM is is an outdated practice denying lation. Circumcision helps to one of the rites of passage into a woman’s self-fulfillment, maintain sexual harmony in the womanhood and into the tribe. g rossly reducing her sexual household as it limits sexual P r events . S o m e p l e a s u re, increasing depre s s i o n , excitement for both parties. ethnic groups believe that the and may even lead to suicide. C i r cumcision distinguishes clitoris can kill a first born child Religious. T h e re is clearly the indigenous from the non - and subsequent children if the no basis whatsoever in any re l i - i n d i g e n o u s . A woman’s identity head touches the clitoris. This gion for the practice of infibula- is tied to circumcision. Marriage essential ritual is believed to tion (Van der Kwaak, 1992). and children are the only means e n s u re quick and easy labor. Those knowledgeable in the

UROLOGIC NURSING / March 1999 / Volume 19 Number 1 15 teachings of the Koran claim a re used to close the bleeding Morris (1996) identified the that nowhere is female circ u m- vaginal lips together. Ropes of attitudes of immigrant Somali cision demanded. In fact, it is goatskin are used to tighten the men and women living in San often interpreted that to mutilate child’s thighs together for a Diego toward the practice of the body in any way actually healing period of 2 weeks. FGM. Both men and women violates the Koran (Abu-Sahlieh, In recent years medically s t r ongly supported the continu- 1994). God created women trained midwives and nurses are ation of FGM with the emerg i n g intact and circumcision destro y s p e rf o rming the pro c e d u re using theme: tradition, religion and his work. Critics of the practice the prestige and knowledge of c u l t u re must continue. The fol- note that FGM is not integral to antisepsis, local anesthesia, and lowing quotes express their the Muslim faith because it is sterile suturing to win more v i e w s . not practiced in , a ffluent clientele from the tradi- Views of men. “It is impor- the spiritual home of Islam. tional circ u m c i s e r. tant for a man to have an uncir- A traumatic experience. cumcised woman, but for the FGM can have lifelong mental Cultural Significance and sake of culture we take circ u m- and sexual health consequences Attitudes To w a r d FGM cised women.” “Somali people with many complications asso- It has been theorized that do it because of tradition. It is ciated with the pro c e d u re. It has the practice of excision re s u l t e d our culture, passing from grand- been described as one of the f r om primitive man’s desire to father to father. It is very dan- “ T h r ee Feminine Sorrows” — gain mastery over the female g e r ous, but people are the sorrows on the day of muti- sexual function. Excision was re s i g n e d . ” lation, those of the wedding thought to reduce a woman’s Views of women. “ A l l night, and those with the birth sexual desire. The focus of this women will become pro s t i t u t e s of a baby. These sorrows re l a t e d e s i re is believed to be the cli- if not closed. Men will not to the tissue damage and pain toris and excision is believed to marry you...” “I’ve been raised associated with each incident p r otect a woman against her with my mother, my grand- ( F o u rc roy, 1998). s t r ongly sexed nature, saving m o t h e r, and great grandmother, A b a n d o n m e n t . A woman her from temptation, suspicion, who have all been circ u m c i s e d . s u ffe ring from the complica- and disgrace, while pre s e r v i n g This is our tradition, our cul- tions of FGM, unable to have her chastity. The son-in-law of t u re...” “Circumcision pro v i d e s sex and/or to bear childre n , is quoted as saying, safety for our girls.” may be abandoned by her hus- “Almighty God created sexual band and isolated from the re s t d e s i re in ten parts; then he gave E f fects of FGM of her community. nine parts to women and one to C i rcumcised women accept- men” (Brooks, 1995). This belief ed their pain and suffering as P e rf o r mers and Decision must be seen in the context of the common lot of women. Makers for Circ u m c i s i o n societies where virginity for a Excerpted quotes best describe Despite the fact that many woman is an absolute pre re q u i- their feelings. “Now I have pain educated men are aware of the site for marriage. So strong is a c r oss my stomach all the time. physical and psychological dis- the association of mutilation I think it is worse since the advantages of female circ u m c i- with premarital chastity that in baby.” “When I make love with sion, the practice is allowed to many areas a uncircumcised girl my husband, I can’t handle it. I continue. The final decision is ridiculed and forced to leave don’t want to see him because I whether to perf o rm the rite and the community. Regardless of have a lot of pain.” “I had to be the type of circumcision to be her virginity, she will have little cut and cut, lots of pain and p e rf o rmed is left to mothers, or no chance of marriage. Both s c reaming. I hurt every time I grandmothers, and the elderly men and women believe that go to the bathroom. The itching w o m e n f o l k . excision makes a woman more is the worst. Infection, the bac- The grandmother or an attractive and somewhat more teria I know live up there. I o l d e r, highly respected woman physically appealing, more wash with very hot water, and leader who controls the tradi- completely feminine. It is thus a then use salt. I scratch so badly tional secret societies or a tradi- ritual deeply embedded in the it bleeds. It’s horrible” (Morris, tional birth attendant is the cir- social fabric, wrapped in a cloak 1 9 9 6 ) . cumciser who uses a kitchen of religious and moral tradi- knife or any sharp instrument tions, and girded by long-held C o m p l i c a t i o n s with the aid of her sharp finger- beliefs regarding the pro p e r The effects of FGM on girls nails. Acacia thorns or thre a d s place and behavior of women. and women happen in utero, at

16 UROLOGIC NURSING / March 1999 / Volume 19 Number 1 birth, and all through life. quences of FGM are partly a c h a r ge seriously affecting the During the antenatal period, result of the practice being per- marital relationship. Cysts and m a t e rnal infections especially, f o rmed under unhygienic con- abscesses result from damage to urinary tract infections with ditions with unsterile instru- the Bartholin’s duct. The duct’s mixed organisms, are higher in ments and unskilled attendants. mucous secretion accumulate, mothers who are circ u m c i s e d The bandaging of the legs f o r ming cysts which later ( B a k e r, Gilson, Vill, & Cure t , together interf e res with wound become infected and form 1993). These conditions pre c i p i- drainage, promoting the abscesses on the vulva. tate pre m a t u re labor. During the upward spread of infection to C h r onic pelvic inflammation birthing process, prolonged and the vagina, , and adnexa. and pelvic congestion lead to obstructed labor adds more Abscesses and gangrene and d y s m e n o r rhea, or painful men- s t r ess to the baby and leads to systemic infections with sep- struation as a result of the small g r eater risk for perinatal fetal ticemia and death result if infec- vaginal opening obstructing the hypoxia, brain damage, and tions are not treated adequately. menstrual blood flow. It can intrauterine death. Tetanus is another serious also lead to , FGM is associated with f o rm of infection and often fol- which is an accumulation of many physical and mental lows FGM within or up to 14 blood and blood clots in the health consequences. In one days. It accounts for 50% to 60% uterus and/or vagina re s u l t i n g study, 83% of women whose mortality within the first 10 f rom the inability of blood to genitals had been mutilated days. It is most prevalent in pass through the vaginal open- re q u i red attention at some time a reas where immunization is ing. A young teenager can pre- in their lives for problems re l a t- inadequate and where circ u m c i- sent with abdominal distention, ed to FGM (Institute for sion is perf o rmed without asep- pain, and malodorous dis- Development Training, 1993). tic techniques. c h a r ge, which may be misdiag- Acute complications (all The use of unsterile instru- nosed as a pre g n a n c y . t y p e s ) . Studies show a signifi- ments and perf o rming the pro- M a l f o rmations and scarring cant increase in the occurre n c e c e d u re in groups increases the resulting from FGM can make of severe asphyxia in infants chance of transmitting hepatitis gynecologic examination includ- b o rn to circumcised mothers. Of B and HIV infections. ing direct visualization of the n e w b o rns born to circ u m c i s e d , vagina, or diff i- mothers, 5.4% have Apgar Gynecologic Pro b l e m s cult. Bimanual or speculum s c o res of five or less, compare d Many gynecologic pro b l e m s examination on an infibulated to 2.4% of newborns born to a re attributed to the practice of young girl or woman cannot be u n c i r cumcised mothers. Infant FGM. Infibulation and excision p e rf o r m e d . mortality rates are high in coun- a re the most severe types of tries where female circ u m c i s i o n genital mutilation. They can U r ologic Complications is practiced. seriously affect the health of a Acute urinary re t e n t i o n . A H e m o r r hage, shock, and woman throughout life, even very common occurrence in the d e a t h . Chance of hemorrh a g e after the de-infibulation pro c e - first 2 to 4 days following the i n c r eases with the extensiveness d u re . p ro c e d u r e is acute urinary of the cut during the perf o r- Keloid form a t i o n . S e v e r e retention. Causative factors mance of the pro c e d u re. Severe disfiguring scarring is more include pain and burning sensa- h e m o r r hage can result either common among black people tion of urine on the raw wound, f r om the dorsal of the cli- as they are more prone to form fear of passing urine on the raw toris or from the labial branches keloids especially if the wound genitalia, damage to the ure t h r a of the pudendal artery immedi- gets secondary infections with and its surrounding tissue, cov- ately after the pro c e d u re, often p rol ongation of the healing ering the external meatus with a resulting in hypovolemic shock p r ocess. The repeated incisions skin flap after infibulation, and and death. Shock can re s u l t that are needed during each scar tissue around the urinary either from severe pain and fear causes more scarring, outlet contracting and re s t r i c t i n g or both (Calder et al., 1993). keloid formation, secondary the opening. Fatal secondary hemorrh a g e s t r i c t u re formation, and disfig- R e c u r r ent urinary tract f r om the infected wound is a u r e m e n t . i n f e c t i o n . Girls and women common cause of death. C h r onic vaginal and pelvic who have had the FGM per- is common, secondary i n f e c t i o n s . C h r onic pelvic infec- f o rmed, particularly Type 3, are to hemorrh a g e . tions lead to chronic pain, mal- m o re prone to re c u r rent urinary I n f e c t i o n . The health conse- o d o r, and chronic vaginal dis- tract infections. The presence of

UROLOGIC NURSING / March 1999 / Volume 19 Number 1 17 the skin flap after infibulation gone FGM and removal of the P s y c h o l o g i c p r events proper hygiene and clitoris suffer from anorg a s m i a . C o m p l i c a t i o n s i n c r eases the chance of local Painful intercourse (dyspare u- Apart from the physical irritation and urinary stasis lead- nia) is secondary to a very nar- h a rm inflicted by FGM, there are ing to bacterial infection. row vaginal opening or exces- psychologic problems which, C h r onic retention of urine sive scarring. can unfortunately, little attention has and vaginal secretions can lead also result from presence of a been directed. This entire expe- to cystitis, , and cervici- d e rmoid cyst that makes vaginal rience is very traumatic. There is tis which may develop into i n t e r course painful, unpleasur- not enough re s e a rch available to c h ronic pelvic inflammation and able, and difficult or sometimes d e t e rmine the extent of the psy- c h ronic re c u r rent cystopy- impossible. chologic harm that is re p re s s e d e l o n e p h r i t i s . Persistent infections cause in the child’s subconscious. It is : Urinary and re c t a l . the blockage of the fallopian only gradually expressed at later Obstructed labor occurs due to tubes leading to or a stages of growth and develop- n e c r osis of the vaginal wall, conception ending with a tubal ment through negative behavior. caused by constant pre s s u re of p r e g n a n c y . In childhood, behavioral baby’s head on the posterior changes include acute wall of the and Obstetrical Complications states, anger, distress, and low the anterior wall of the re c t u m The uncommon physiology self-esteem. Problems pre and during prolonged labor. Both of a woman with FGM incre a s- p o s t c i r cumcision include lack of conditions are very upsetting to es the risks for both the unborn sleep. Older sisters experience the patient. Some are very upset and the pregnant mother. helplessness as they are unable as they constantly smell of During , infections to protect younger sisters fro m urine; others suffer fre q u e n t f r om cysts and vaginal and uri- the trauma of circ u m c i s i o n . as urine usually nary tract infections can lead to In adolescents and young seeps through the cervical os fetal abnormalities and demise women, feelings of inadequacy, and poisons the growing fetus (Hanly & Ojeda, 1995). Delay in low self-esteem, and fears for (Koso-Thomas, 1992). l a b o r, prolonged second stage, health are some of the effects of Calculus formation. T h e uterine inertia, and obstructed FGM. In addition, young s t r i c t u re formation and exces- labor are all consequences of women are concerned about sive scarring secondary to the infibulation resulting in perineal their sexuality and desirability to damage caused by the pro c e - lacerations, vesico-vaginal and a future partner. Failure to con- d u r e increases stasis of urine recto-vaginal fistulae, injury to ceive and/or survive the birthing leading to urinary tract stone the , and late uterine pro- p r ocess are persistent fears. f o rm a t i o n . lapse. Many women respond to cir- Damage to the urethra and An anterior is cumcision with deniaI of sexual- a n u s . Genital mutilation is per- always necessary, in addition to ity and frigidity. f o rmed during childhood. The the posterolateral , Women who question the instruments used for cutting particularly in the infibulated tradition experience anger and may be too large or blunt. The primigravida. In women deliv- guilt feelings at having to disrupt unskilled person perf o rming the e red by lay midwives, a signifi- the family. Psychosomatic symp- s u rgery with the struggling child cant number of women develop toms of circumcised women f o r cibly held in the lithotomy puerperal sepsis. Postpartum include general fatigue, back- position may injure the delicate h e m o r rha ge is common in ache, headache, and loss of adjoining structures such as the infibulated women, as they sleep, chronic anxiety and anus, urethra, or tendons re s u l t - need more cutting and fre- d e p ress ion, insecurity, confu- ing in urinary and fecal inconti- quently have tears in the vagina sion as to why this pro c e d u re nence. Several cases of perm a- and perineum. Many physicians was done, anxiety over any sur- nent incontinence have been in the United States have cho- gical pro c e d u re, a sense of loss reported. Cases of damage to sen to perf o rm a Caesarean sec- of sexuality, loss of libido, the vaginal walls leading to total tion instead of intervening with absence of , neuro s i s , occlusion of the vaginal intro i- the infibulation scar (Baker et and psychosis (Abu-Sahlieh, tus and hence hematocolpos al., 1993). Caesarean sections 1994; Toubia, 1994). have also been re p o r t e d . a re also perf o rmed when early tearing occurs or there are signs C o n c l u s i o n s Sexual Health Pro b l e m s of fetal distre s s . FGM is a poorly understood, Women who have under- highly controversial practice,

18 UROLOGIC NURSING / March 1999 / Volume 19 Number 1 passed on from generation to R e f e re n c e s Jordan, J.A. (1995). Female genital mutilation generation and enforced by cus- Abu-Sahlieh, S.A.A. (1994). To mutilate in the (female circumcision). British Journal of name of Jehovah or Allah: Legitimization and , 101, 94-95. tom and religion. The practice of of male and female circ u m c i s i o n . Koso-Thomas, O. (1992). The circumcision of female circumcision varies Medicine and Law, 13, 575-622. women: A strategy for eradication. among diff e r ent ethnic gro u p s B a k e r, C.A., Gilson, G.J., Vill, M.D., & Cure t , Atlantic Highlands, NJ: Zed Books. L.B. (1993). Female circumcision; obstet- Lane, S.D., & Rubinstein, R.A. (1996). Judging and the type of operation ric issues. American Journal of Obstetrics the other: Responding to traditional depends on the religious and and Gynecology, 169(6), 1616-618. female genital surgeries. Hastings Center traditional beliefs of the people. B r ooks, G. (1995). Nine parts of desire. New Report, 26(3), 31-40. York: Doubleday Dell Publishing Morris, R.I. (1996). Attitudes of Somali men The increase in refugees and Company. toward female genital mutilation. F i n a l immigrants, especially fro m B u r eau for Refugee Programs. (1992). Wo r l d Report to the Department of Health Somalia, Ethiopia, Sudan, and refugee re p o r t . Washington, DC: U.S. Services, San Diego County. San Diego: Department of State. San Diego State University. parts of Nigeria and Egypt, has C a l d e r, B.L., Brown, Y.M.R., & Rae, D.I. (1993). The Minority Rights Group. (1985). Female cir - drawn attention to FGM as a Female circumcision/genital mutilation: cumcision, excision and infibulation public health concern for health Culturally sensitive care. Health Care for (Report No. 47). London: Expedite Women International, 14, 2 2 7 - 2 3 8 . Graphic, Ltd. c a r e providers in North America F o u r c r oy, J.L. (1998). The three feminine sor- Schwartz, R.L. (1994). Multiculturalism, medi- (Abu-Sahlieh, 1994). The rite is rows. Hospital Practice, 7, 15-16, 21. cine, and the limits of autonomy: The p e r f o rmed privately, making it Goodwin, J. (1994). Price of honor: Muslim practice of female circ u m c i s i o n . women lift the veil of silence in the Cambridge Quarterly of Healthcare exceedingly difficult to measure Islamic world. Boston: Little & Bro w n . Ethics, 3, 431-441. its incidence. Hanly, M.G., & Ojeda, V.J. (1995). Epiderm a l Toubia, N. (1995). Female genital mutilation: FGM is a highly sensitive inclusion cysts of the clitoris as a com- A call for global action. New York: RAIN- plication of female circumcision and B O . and complex issue. FGM prac- pharaonic infibulation. Central African Toubia, N. (1994). Female circumcision as a ticing people consider the con- J o u rnal of Medicine, 41(1), 22-24. public health issue. The New England tinuance of culture and tradition Institute for Development Training. (1993). J o u rnal of Medicine, 331(11), 712-716. Female genital mutilation. Module 10. Van der Kwaak, A. (1992). Female circ u m c i- vital to self-respect. They per- Chapel Hill, NC: IDT. sion and gender identity: A questionable ceive themselves as active par- Jones, W.K. (1997). Who is at risk in the alliance? Social Science and Medicine, 6, ticipants in the larger society United States? Public Health Reports, 112, 7 7 7 - 7 8 7 . 3 6 9 - 3 7 7 . and believe that opinion leaders respect their intention to be responsible parents and honor- able community members. It must be re m e m b e r ed that FGM is not regarded by them as abuse. Health care professionals in the United States have very little knowledge of FGM. Managing complications of FGM, cultural attitudes, and sensitivities toward this practice should become part of the curricula for students in health care pro- grams. Research, seminars, and workshops for health care prac- titioners are essential for a d d r essing this fast-gro w i n g p r o b l e m . Interdisciplinary health care teams with community health c a r e re p resentatives and com- munity religious leaders should f o rm coalitions, listen to each o t h e r, and jointly plan and implement treatment centers and health education pro g r a m s to eradicate FGM among prac- ticing populations now re s i d i n g in North America. •

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