FGM regarding social context of women health

1. By mdsd 2017 1

2. Terminology
Global prevalence
Egypt prevalence
Misperceptions and reasons
Risk factors
Types & complications
Social dynamics of FGM
Reasons to stop FGM
Approaches promoting the abandonment of FGM/C
By mdsd 2017 2

3. Terminology
 female genital mutilation/cutting (FGM/C)
(UNICEF)
 female genital cutting
 female genital mutilation (WHO)
 female genital circumcision
By mdsd 2017 3

4. • Clitoridectomy:
Partial or total removal of the clitoris and/or the prepuce
• Infibulation:
Excision of part of the external genitalia and stitching of the
vulvovaginal opening
• Defibulation:
Reopening the vulvovaginal opening in a woman who has previously
undergone infibulation, for sexual intercourse or childbirth
• Reinfibulation:
Stitching closed the vulvo-vaginal opening or labia following
defibulation
By mdsd 2017 4

5. By mdsd 2017 5

6. FGM/C:
• FGM/C:
All procedures involving the partial or total
removal of the external genitalia, or any other
injury (i.e., pricking, piercing, incising, scraping,
cauterization) to the genital organs for non-
medical reasons (WHO)
By mdsd 2017 6

7. • FGM/C practices took place as far back as 5,000 years ago;
Egyptian mummies have been identifi ed as having
undergone the procedure
By mdsd 20177

8. By mdsd 20178

9. Global prevalence
http://www.unicef.org/media/files/FGMC_2016_brochure_final_UNICEF_SPREAD.pdfBy mdsd 2017 9

10. Global prevalence
By mdsd 2017 10

11. Global prevalence
By mdsd 2017 11

12. By mdsd 2017 12

13. By mdsd 2017 13

14. By mdsd 2017 14

15. By mdsd 2017 15

16. By mdsd 2017 16

17. By mdsd 2017 17

18. By mdsd 2017 18

19. By mdsd 2017 19

20. By mdsd 2017 20

21. By mdsd 2017 21

22. By mdsd 2017 22

23. By mdsd 2017 23

24. By mdsd 2017 24

25. By mdsd 2017 25

26. Prevalence change
By mdsd 2017 26

27. By mdsd 2017 27

28. By mdsd 2017 28

29. Misperceptions
 Is supported or mandated by religion
 Is an important cultural tradition that should not
be questioned or stopped, particularly not by
outsiders
 Prepares a girl for adulthood and marriage
 Reduces a women’s sexual desire, preserves
virginity and prevents promiscuity
 Improves male sexual pleasure and virility
 Facilitates childbirth by increasing a women’s
pain tolerance
 Facilitates cleanliness
 Prevents the clitoris from growing excessivelyBy mdsd 2017 29

30. By mdsd 2017 30

31. Reasons for performing FGM
(WHO)
There are a variety of reasons why female
genital mutilation continues to be practiced.
The reasons given by practicing
communities are grouped as follows:
 Socio-cultural reasons.
 Hygienic and aesthetic reasons.
 Spiritual and religious reasons.
 Psycho-sexual reasons.
By mdsd 2017 31

32. Socio-cultural reasons
• Some communities believe that unless a
girl’s clitoris is removed, she will not
become a mature woman, or even a full
member of the human race.
• A non-circumcised woman blinds anyone
attending to her birth or causes the death
of the husband;
• Female genital mutilation is believed to
ensure a girl’s virginity.
By mdsd 2017 32

33. • Women’s access to land and security is
through marriage, and only excised
women are considered suitable for
marriage.
• In communities that practice FGM, girls
are generally subjected to powerful social
pressure from their peers and family
members to undergo the procedure.
By mdsd 2017 33

34. • Typically, the traditional excisor is a
powerful and well respected member of
the community, and FGM is her source of
income.
By mdsd 2017 34

35. Hygienic and aesthetic reasons
• In FGM practicing communities, it is
believed that a woman’s external genitalia
are ugly and dirty, and will continue to
grow ever bigger if they are not cut away.
Removing these structures makes a girl
hygienically clean.
• FGM is believed to make a girl beautiful.
By mdsd 2017 35

36. Spiritual and religious reasons
• Some communities believe that removing
the external genitalia is necessary to make
a girl spiritually clean and is therefore
required by religion.
• In Muslim societies which practice FGM,
people believe that it is required by the
Koran. However FGM is not mentioned in
the Koran.
By mdsd 2017 36

37. Psycho-sexual reasons
• FGM prevents premarital sex and preserves
virginity – an uncut clitoris grows big and
activates intense sexual desire;
• It is also believed that the tight vaginal orifice
of an infibulated woman, or a woman who
has had chemicals placed in the vagina in
order to narrow it, will enhance male sexual
pleasure, in turn preventing divorce or
unfaithfulness.
By mdsd 2017 37

38. • In some communities it is believed that
excising a woman who fails to conceive
will solve the problem of infertility.
By mdsd 2017 38

39. Economic
• Girls are rewarded with presents after the
operation;
• Non-circumcised girls have little or no chance
of getting married – they will be a financial
burden for the family;
• Family might loose high position in society
(lands, jobs…).
By mdsd 2017 39

40. • Women are economically dependent upon
males – a lot of privileges are guaranteed
through marriage.
• Desire of men to gain power over female
sexuality.
• FGM contributes to the oppression of
women.
By mdsd 2017 40

41. Risk Factors
FGM/C is typically performed at some point
between infancy and age 15 years.
In half the 29 countries where FGM/C is most
commonly practiced, >80% of cutting occurs in
girls <5 years of age.
By mdsd 2017 41

42. Prevalence varies greatly among countries and there is
also substantial variation within countries.
Countries where the prevalence of FGM/C is highest
(>80%) include Somalia, Guinea, Djibouti, Egypt, Eritrea,
Mali, Sierra Leone and Sudan.
By mdsd 2017 42

43. Risk Factors
The prevalence of FGM/C is highest among
Muslim girls and women, but this is not always
the case.
FGM/C is also reported among individuals with
other religious backgrounds.
FGM/C prevalence tends to be lower in wealthy
urban residents, perhaps because they have
exposure to a greater number of socio-cultural
networks.
By mdsd 2017 43

44. The prevalence of FGM/C is generally lower
in relatively wealthier households.
The prevalence of FGM/C is generally
highest among daughters of women with no
education.
The chances that a girl will undergo FGM/C
are significantly increased if her mother has
been cut.
Risk Factors
By mdsd 2017 44

45. DONE BY WHOM
• Mainly by Traditional Birth Attendants
• Relative to girls
• Professional health personal include
Physicians and nurses
By mdsd 2017 45

46. By mdsd 2017 46

47. By mdsd 2017 47

48. By mdsd 2017 48

49. By mdsd 2017 49

50. By mdsd 2017 50

51. By mdsd 2017 51

52. Types of FGM/C
By mdsd 2017 52

53. By mdsd 2017 53

54. By mdsd 2017 54

55. By mdsd 2017 55

56. By mdsd 2017 56

57. By mdsd 2017 57

58. COMPLICATIONS
FGM/C is recognized as harmful to girls and women,
both physically and psychologically, and has no
medical benefit.
The occurrence of trauma and medical complications
may relate to:
• The type of FGM/C
• The type of practitioner
• The absence or misuse of anesthesia
• The type of equipment used (scissors, razor
blades, and/or broken glass may be used)
By mdsd 2017 58

59. By mdsd 2017 59

60. EARLY COMPLICATIONS
• Early complications are usually treated by a
local practitioner, and patients may only
present to a health care professional for
complications that are significant or occur well
after the procedure.
• Early complications include severe pain,
bleeding, infection and urinary retention and
are associated more frequently with FGM/C
types 2 and 3.
By mdsd 2017 60

61. By mdsd 2017 61

62. By mdsd 2017 62

63. Later complications
Type of
complication
Strongly associated with FGM/C
(in case reports and/or cohort
studies)
Fertility/
sexuality
Anorgasmia, apareunia, decreased
satisfaction, dyspareunia, lack of
sexual desire, vaginal dryness
Infection Bacterial vaginosis, herpes simplex
virus
Pain Clitoral neuroma, dysmenorrhea;
lower abdominal, vaginal or vulvar
pain
By mdsd 2017 63

64. Psychological Anxiety, depression, post-traumatic
stress disorder, somatization
Scarring Fibrosis, hematocolpos, keloids, labial
fusion (partial or complete),
sebaceous cysts, vaginal stenosis,
vulvar abscesses
Urinary Chronic urinary tract infections, meatal
obstruction, meatitis, urethral stricture,
urinary crystals
Source: Hearst AA, Molnar AM. Female genital cutting: An evidence-based approach to clinical
management for the primary care physician. Mayo Clin Proc 2013;88(6):618-29. Adapted with
permission.
LATE COMPLICATIONS
By mdsd 2017 64

65. WHO’s Guidelines on the Management of Health
Complications from Female Genital Mutilation
By mdsd 2017 65

66. By mdsd 2017 66

67. By mdsd 2017 67

68. Social Dynamics of FGM
A social convention:
Where FGM is a social convention, the social
pressure to conform to what others do and have
been doing, as well as the need to be accepted
socially and the fear of being rejected by the
community, are strong motivations to perpetuate
the practice.
In some communities, FGM is almost universally
performed and unquestioned.
By mdsd 2017 68

69. A social convention
• Families will abandon FGM/C
only when they believe that
most or all others will make the
same choice at the same time.
Marriage
FGM
By mdsd 2017 69

70. SOCIAL NORMS
 In most practicing communities, however, social
approval or disapproval, manifested through
community and peer pressure, also play important
roles in perpetuating the practice.
 Failure to conform to FGM/C leads to social
exclusion, ostracism, disapproval, rebuke or even
violence – in addition to having an effect on a girl’s
marriageability.
 Conformity, on the other hand, meets with social
approval, brings respect and admiration, and
maintains social standing for a girl and her family in
the community.
By mdsd 2017 70

71. ASSOCIATED BELIEFS
• FGM is often motivated by beliefs about what is
considered acceptable sexual behaviour. It aims to
ensure premarital virginity and marital fidelity.
• FGM is in many communities believed to reduce a
woman's libido and therefore believed to help her
resist extramarital sexual acts. When a vaginal
opening is covered or narrowed (type 3), the fear of
the pain of opening it, and the fear that this will be
found out, is expected to further discourage
extramarital sexual intercourse among women with this
type of FGM.
By mdsd 2017 71

72. ASSOCIATED BELIEFS
• Religion is often cited, particularly by Christians and
Muslims, as a reason for carrying out FGM/C, although the
practice predates Christianity and Islam.
• Most Christians and Muslims around the world, however, do
not carry out FGM/C on their daughters, sisters and wives
• Religious leaders take varying positions with regard to FGM:
some promote it, some consider it irrelevant to religion, and
others contribute to its elimination.
By mdsd 2017 72

73. Associated beliefs
• In some communities, FGM/C may be an
important part of a girl’s transition to
adulthood and marriage-ability and may
be accompanied by a coming-of-age
ceremony or ritual.
• But, In many communities, girls are cut at
a very young age and the practice is
conducted in private and without fanfare.
By mdsd 2017 73

74. ASSOCIATED BELIEFS
• At times, the practice is associated with
bodily cleanliness and beauty, where girls
who have undergone FGM/C are
considered physically ‘clean’.
• If communities are to make the decision to
abandon the practice, credible new
information must be introduced from
trusted sources.
By mdsd 2017 74

75. By mdsd 2017 75

76. By mdsd 2017 76

77. By mdsd 2017 77

78. By mdsd 2017 78

79. By mdsd 2017 79

80. By mdsd 2017 80

81. By mdsd 2017 81

82. By mdsd 2017 82

83. By mdsd 2017 83

84. By mdsd 2017 84

85. By mdsd 2017 85

86. • There are six main approaches undertaken to
end FGM/C:
1. Alternative Symbolic Rituals (ASR’s):
Symbolic ceremonies that do not harm the body.
2. Risks to Health Approach: Health workers
as key agents advocating for change emphasises
the risks to health from FGM/C. However it
should be noted this approach has also
influenced the increased medicalization of the
practice by some communities
By mdsd 2017 86

87. 3. Human Rights: Emphasises FGM/C as a violation
of the universal human rights of women and children
4.Provision of reproductive information and
educative materials that empower women
Community Based Eradication
5. Positive Deviance: whereby influential
individuals in the community publicly declare their
opposition to the practice, and work to influence
others to do the same
6.Directly targeting excisors/Traditional Birth
Attendants and helping them to find an
alternative source of income
By mdsd 2017 87

88. • Efforts to stop this unintended consequence were
initiated by WHO in 1979 at the frst international
conference on FGM, held in Khartoum, Sudan,
where WHO established that it is unacceptable
to suggest that performing less invasive forms
of FGM within medical facilities will reduce
health complications.
By mdsd 2017 88

89. FGM/C AND GENDER EQUALITY
• Where girls and women are expected to follow
prescribed gender roles within the family and
community, they may even endorse the
discriminatory norms that are meant to control
them.
• Communities that recognize that girls and women
have rights to physical and mental integrity, to
freedom from discrimination and torture and to the
highest standard of health and to the right to life,
are empowered to collectively review,
deliberate and change existing discriminatory
practices.
By mdsd 2017 89

90. FGM violates a series of well-established, global human
rights principles, norms and
standards including:
the right to the highest attainable standard of health;
the right to equality and non-discrimination on the basis
of sex;
the right to life (when the procedure results in death);
the right to freedom from torture, cruel, inhuman or
degrading treatment or punishment;
the rights of the child.
By mdsd 2017 90

91. By mdsd 2017 91

92. By mdsd 2017 92

93. By mdsd 2017 93

94. By mdsd 2017 94

95. • During the guideline development meeting
in September 2015, the participants adopted
three guiding principle statements, fve
recommendations and eight best practice
statements covering health interventions for
preventing and treating health risks of FGM.
By mdsd 2017 95

96. By mdsd 2017 96

97. • FGM, whether carried out in a hospital or any
other modern setting, is willful damage to
healthy organs for nontherapeutic reasons. It
violates the injunction to “do no harm”, and is
unethical by any standards.
By mdsd 2017 97

98. programmes and approaches promoting the
abandonment of FGM/C
• Understand the social dynamics of decision-
making related to FGM
• Work with – not against – cultural and
community practices and beliefs (reinforcing
positive cultural values can be more effective)
By mdsd 2017 98

99. • Target local, national and international
levels of influence (implementation of
laws)
• Use a comprehensive and rights-based
approach(focused on reducing gender
discrimination, improving social justice and
supporting human rights, community
development, and empowerment and
literacy among women and girls )
By mdsd 2017 99

100. Basic requirements for elimination of
FGM
The elimination of FGM is a painstaking process
that requires long-term commitment and the
laying of a foundation that will support successful
behaviour change. That foundation includes:
• strong and capable anti-FGM programmes at the
national, regional and local levels
• a committed government that supports FGM
elimination with policies, laws and resources
By mdsd 2017 100

101. • making FGM a mainstream issue integrating
FGM prevention into all relevant government
and non-government programmes, e.g. health,
family planning, education, social services,
human rights, religious programmes etc.
• health care providers at all levels who are
trained to recognize and manage the
complications of FGM and to prevent the
practice
By mdsd 2017 101

102. • good coordination among governmental and
nongovernmental agencies
• advocacy that encourages a supportive policy and
legal environment for the elimination of FGM,
increased support for programmes, and public
education
• empowerment of women.
By mdsd 2017 102

103. By mdsd 2017 103

104. 104

105. 105