Public Health Promotion: Female Genital Mutilation

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Introduction

Sexuality and its psychological aspects compose one of the main driving forces uniting people and shaping their multi-faceted life, including biological, mental, and socio-cultural factors. Within the framework of human values, sexuality is an innate human need and one of the most significant aspects of their existence (Johnsdotter & Essén 2010). Sexual health can be defined as not only the absence of any painful changes in the human body, which can lead to a decrease in sexual function, but also an integral complex of interacting components of sexuality. The paramount aim of sexual health promotion is to provide sexual behaviour basics, contribute to the optimal sexual adaptation and ensure sexual harmony in accordance with the norms of social and personal morality.

This paper will focus on such health issue as female genital mutilation / female genital cutting (FGM / FGC), the practice that still exists in some countries and implies the removal or cutting of women’s genitalia. Despite the current initiatives that are implemented by the World Health Organization (WHO) and other international institutions, FGM is considered as a procedure that purifies a woman and makes her less lustful by some nations, living primarily in African countries.

In fact, this procedure violates female reproductive system and causes physical and psychological suffering. The promotion of the increase in awareness of FGM’s factual role and impact is likely to eliminate it and ensure that women will avoid it. This paper will analyse how cultural, ethical and legal aspects affect the application of FGC in detail. In particular, traditions, beliefs, the perception of women and laws will be examined with the aim of determining the relevance of the existing sexual health promotion initiatives.

Background

Sexuality of a modern person is largely freed from biological determinism and depends largely on psychological and socio-cultural factors. The need for reproduction is separated from the need for sexual satisfaction and communication (Bjälkander et al. 2012). Socialisation of sexuality is manifested in the assimilation of sexual and social norms, a culture conditioned by sexual education and, the development of attitudes, the kinetics and postures of sexual intercourse and the development of attitudes towards sexuality and beauty.

The WHO specified sexual health as “a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence” (Sexual health n.d., para. 1). In this regard, it becomes evident that FGM violates the rights of women to be free of coercion and discrimination. It should be stressed that females are subjected to this procedure against their will and, as a rule, are given no anesthesia, which makes them suffer for the whole life.

Sexual health is considered in terms of a socio-psychological aspect due to the paired nature of sexual function, the formation of a small group (family or partner couple), as well as the current differentiation of male and female roles and stereotypes regarding masculinity and femininity. The formation of sexual behaviour is also influenced by the level of feelings and sexual culture, which, in turn, is affected by the individual psychological characteristics of a person (Relph et al. 2012).

Even though some of women consider FGM as rather violent and painful, they still force their daughters to experience it since the community traditions dictate it. The latter often occurs since only circumcised woman can get married and live happily. This shows the stigmatised nature of FGM that needs to be eliminated by means of sexual health promotion and education of both men and women.

The health issue of FGM was selected since it is a vivid example of how women’s rights are violated in many countries (Erskine 2014). In order to assist women in overcoming this barbaric tradition, it is of great importance to understand it in detail, including causes, conditions and challenges to health promotion actions. According to the United Nations International Children’s Emergency Fund (UNICEF), approximately 8,000 girls are subjected to female circumcision around the world every day (Boseley 2014). This practice exists in 30 countries of the world, and it is especially prevalent in African countries (see Figure 1).

Figure 1. Prevalence of FGM in African countries (%) (Boseley 2014).

In Egypt, Somalia, Ethiopia and Djibouti, more than 90 percent of women underwent this procedure – in most cases, it is performed with little girls (Boseley 2014). However, it should be stressed that the problem cannot be narrowed to the Middle East: in Western countries, there is a growing number of such operations. For example, in the US, there were 168 thousand of them in 1997, and this number achieved 513 thousand in 2015 (Andro et al. 2016).

The World Health Organisation estimates that there are 140 million women in the world who have undergone mutilation. According to the UN International Emergency Children’s Fund, in Somalia, Guinea, Djibut and Egypt, at least nine out of ten women and girls are currently circumcised (Female genital mutilation 2018). The presented evidence proves that the problem of FGM is critical, and there is a need to address it as soon as possible.

The emergence of this tradition was caused by the fact that the genitalia of females were considered unclean. Mutilation was also done in order to reduce sexual pleasure of women, and, as a result, the number of adultery. In some areas, the circumcision of girls is done in infancy, in others – in adolescence (Thomas 2010). The procedure is performed under primitive conditions, and there are many risks associated with psychological state and sexual health.

For example, a girl may get a painful shock or blood infection, which may affect her ability to give a birth and handle other difficult situations (Shell‐Duncan et al. 2013). At the same time, circumcised women can suffer from chronic inflammation, while urination and sexual intercourse can become painful, and childbirth life-threatening. Some women feel pain during the intercourse, and others may completely loose sexual sensations.

There are several types of FGM that depend on a certain nation’s traditions, culture and marital customs. The best case scenario is when girls are cut off a small part of clitoris, and the cruelest operations remove the clitoris hood, clitoris, labia minora and labia, which is called clitoridectomy (Female genital mutilation 2018). Even in the 1950s, this procedure was used in Western medicine to treat female hysteria, nymphomania, epilepsy, and melancholia.

Excision, type two FGM, implies removing the labia minora and clitoris, when the outer folds of skin are either left or cut as well. Infibulation – removing the clitoris and the labia minora and stitching the labia majora, when the vaginal opening is sutured, and a small opening is left for urine, menstrual blood, and intercourse (Mulongo, McAndrew & Hollins Martin 2014). To heal the tissue, the girls’ legs are tied for ten to fourteen days. The type four includes all other non-medical operations on genitalia such as piercing, cauterising, pricking, et cetera.

Exploring Female Genital Cutting in Terms of Cultural, Ethical, and Legal Frameworks

The barbaric traditions of female genital mutilation are fought by international organisations and national governments of those countries that consider the ritual a violation of human rights. However, it is difficult to struggle with traditions without raising the general level of education among the local populations, although, as practice shows, in countries that follow the word of law, this practice remains popular as well. For example, such operations are still common in Somalia, although there has been an active fight against circumcision for many years.

FGM can no longer be considered an exclusively African problem since this is a human rights violation that affected hundreds of millions of women and girls on all continents, as emphasised by Mary Wandia, the director of director of Equality Now, an international human rights organisation. According to the UN estimates, more than 200 million women and girls have been circumcised, and more information has been received on the spread of FGC in India, Colombia, Singapore, Yemen, and Indonesia in the past few years. The main argument of the proponents of this practice is cleanliness, a guarantee that a girl was purified so that she will not try to seduce men. In fact, the point is to destroy her sexuality so that in the end she would be faithful to her husband. This is believed to reduce the number of divorces and adultery.

There are several challenges that impede sexual health promotion actions worldwide. The first of them is the cultural aspect that is inherent in mothers who experienced cutting and bring their daughters to the procedure, which is carried out in an atmosphere of the strictest secrecy. The surgical interventions are usually done either by elderly women assigned to this mission or by ordinary midwives illegally.

In some communities, the operation may be carried out by relatives and hairdressers, who use shaving accessories. Worden (2012) states that traditions and prejudices are rather strong in those communities that practice FGC and consider it imperative for making women clean and applicable for marriage. It goes without saying that such a based perception of women violates their rights as humans, yet this factor is the most critical argument of FGM proponents.

The second factor is the fact that the given practice is protected by communities and held in secret from law enforcement agencies and people who combat it. Speaking about the psychological state of a woman who has undergone an operation, Yoder, Wang and Johansen (2013) note that it is equal to the shock of the experienced sexual violence. The damage that the removal of the clitoris causes to the health of a woman is enormous: from post-traumatic syndrome, psychosis and phantom pain to loss of interest in life.

A lack of sensitivity of the genital organs and any sexual activity along with the interest in it may eventually lead a woman in deep depression. All the mentioned issued are kept in petto since and not communicated to the outside world. Therefore, it is especially difficult to promote awareness of the adverse impact of FGC among such populations.

As a vivid example, Horner (2016) notes the topic of women’s health in the mountainous regions of Dagestan that still taboo. The author states that it is almost impossible to directly ask about such delicate questions as the local population do not answer. This tradition is tried to preserve, protect, and prevent the invasion of others as such topics are not discussed with outsiders. This is why the majority of gynecologists, forensic experts and guardianship officers surveyed by the Legal Initiative did not know about the existence of female circumcision in the republic of Dagestan. All this suggests the idea that women do not want, are afraid of, or do not consider it necessary to contact law enforcement agencies and report about the practice. Unfortunately, for many of them, injury is not a crime, but a custom that must be respected, and women are ready to keep the practice and pass it on to the next generations.

One more challenge is associated with the fact that European and American agencies that struggle to eliminate FGM continually encounter underground surgeons who perform female genital cutting. One of the most notorious recent cases is the case of the doctor Jumana Nagarwala, who has practiced circumcision in Detroit for twelve years, while the girls were brought to her from different states (Laughland 2017). The mentioned person denies her guilt, assuring that she only fulfilled the religious custom of the Indian sect Daoudi Bohra, in which she is a member. This case clearly demonstrates that there are still many persons who protect this violent tradition due to unawareness of its negative consequences and potential difficulties women may encounter in their life.

In addition, it is essential to mention that FGM is one of the factors stimulating polygamy: a man is not satisfied with his wife, as the intercourse is painful and unpleasant for her, so he takes another one. The reaction of women to the second wife is controversial, although it must be said that the first wife may agree or disagree on the appearance of a new spouse (Wade 2011). As a rule, those who live in cities and tend to be educated are against this practice – they want a European style family. In villages, a woman is often glad that her husband will take another wife as it provides the opportunity to share the work with someone and reduce the occurrence of painful sexual sensations.

Nevertheless, it should be stressed that there is a tendency to improve. Speaking about the most violent practices of circumcision, then in the overwhelming majority of countries, they do not make them and do not even talk about them. Mitike and Deressa, (2009) suggest that with the elimination of the removal of the clitoris, the most common practice in Africa, it will be finished sooner or later based on raising people’s awareness. In this connection, it is important to clarify that many women do not even associate their health problems with injuries caused to them, and this is not only the risk of infections, it is the absence of sexual desire, vaginal dryness and painful sexual intercourse.

The key strategy that is useful to address such a situation is the educating work with the elder representatives of these communities. In particular, it seems to be necessary to communicate with them and provide the scholar studies that prove how dangerous the operation can be for females (Nour 2012). In addition, films and videos based on the interviews with the victims of FGC may also be useful to explain the elder adults the impact of the operation. It is also possible to recommend that the promotion should be steady and peaceful to ensure that communities perceive the opponents of the procedure appropriately, without causing any damage. Once the change in their attitudes is achieved, one may expect that the overall level of operations will be reduced and then completely eliminated.

The Egyptian Ministry of Health is constantly fighting this phenomenon. According to the recent studies, the main reasons for this practice are rooted in poverty and a lack of education in rural areas. The former Assistant Minister of Health of Egypt, Saad Hassan, reports that every year the government closes medical centers that perform circumcision. Moreover, doctors who performed operations are taken out of licenses. In 2008, criminal liability for female genital mutilation and amputation was introduced (Fahmy, El-Mouelhy & Ragab 2010).

For doctors, imprisoned for a term of three months to two years and a fine are also introduced. The efforts of the Ministry of Health, nongovernmental organisations, and information campaigns have led to a decrease in the number of female circumcisions among women, but this number continues to be high even though people have a growing understanding of the harm from this operation (Kott 2012). For example, they began to inform the government about the centers in which this procedure is carried out, thus contributing to the closure of similar places.

Speaking of the African female genital mutilation, it is most common in Somalia, the country with the highest percentage of this operation among other African countries. In addition, the given procedure is not considered dangerous there by the local population (The Guardian 2012). According to an Egyptian doctor who works in Somalia, Ismail Gashim, despite the official ban on this operation, the flow of people willing to do it for their daughters from 4 to 11 years old is not weakening (Public Policy Advisory Network on Female Genital Surgeries in Africa 2012).

There is a strong conviction in Somali society, especially among adult women in following traditions that is not related to religion. According to UNICEF statistics, 88 percent of women in Sudan went through a similar operation within the last decade (Koïta & Levin 2012). The example of the mentioned country shows that the efforts of the government do not bring the expected success. The government has set a goal with the support of international organisations to end this phenomenon by 2018 (Lunde & Sagbakken 2014; Modrek & Sieverding 2016). In order to achieve success, the country needs sufficient funding and the work of specialists.

Women should be educated since it is obvious that legislative regulation is not sufficient. To change public opinion, it is of great importance to talk about the problem through the media and special training programs directly to the target populations. The key issue, according to Macklin (2012), is to create support for opposing FGM, so that those families who are against it see that they are not alone.

When creating such support, a chain reaction of failures occurs, and Rebouché (2009) believes that it will take another decade for this practice to completely disappear. Although compared to its thousand-year history, this is a rather short period. Consistent with Cui (2011), the pivotal goal of the future actions combating FGC is to draw attention to the problem of female genital mutilation and the joint initiatives of interested individuals and organisations to contribute as much as possible to its eradication.

The main tasks that can be recommended are to conduct interviews with the respondents, women who have undergone genital surgery in childhood, families, communities, and local experts in in the identified countries (Moore 2013; Simpson et al. 2012). Furthermore, based on an analysis of the interviews, it is significant to show how residents perceive and justify mutilation practices, and, probably, give this phenomenon a legal assessment from the point of view of both national and international law.

Conclusion

In conclusion, it should be emphasised that such health issue as female genital mutilation is a critical problem that violates women’s rights and hearts their bodies, leading to stress, painful sensations during the intercourse, urination and reproductive difficulties, and so on. Among the countries that still practice FGM, there are mainly African ones such as Somalia, Egypt, and Sudan; in some Western cities, it is also possible to find doctors who provide such services. In order to eliminate FGC as a dangerous procedure, it is critical to discuss this problem and attract public opinion, assessing the vulnerable populations and educating them on the role of FGM and its adverse consequences.

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