Tuesday, February 1, 2011

Female Genital Mutilation in Ireland

The young migrant woman sitting across from her doctor has suffered one of the most horrific tortures imaginable. Her smile and relaxed conversation belie her daily discomfort, the agony of her monthly cycle and the enduring nightmare of the day she was held down while a woman cut way her clitoris and part of her labia and then stitched her closed. She was six years old.
Now, in her new home in Ireland, her doctor and others close to her may never know of this most intimate violation, which could seriously compromise her health, both physically and psychologically.
There are thousands of similar stories from women and girls residing in Ireland who have undergone Female Genital Mutilation (FGM). New figures released to Scope show that their numbers are increasing, from 2,585 in 2006 to more than 3,170 last year. This escalation has led to urgent calls for legislation to protect children in practicing communities in Ireland and for more awareness among health care personnel, particularly in the obstetrical field.
FGM involves removal of either a part or the whole of the female external genital organ for cultural, traditional or any other non-medical reasons. This is global phenomenon that has claimed its casualties mostly from Africa and countries of the Middle East.
Also referred to as female genital cutting or female circumcision, this brutal procedure is most commonly performed between the ages of four and eight, although it can take place at any age from infancy to adolescence, usually without benefit of anaesthesia, surgical implements or sterile surroundings.
Infection rates are high, and other immediate complications include post-operative shock and bleeding. Some girls do not survive but those who do will live with the emotional and physical damage, including chronic infections of the bladder and vagina, dysmenorrhoea, childbirth obstruction and obstetric fistula.
AkiDwA, the African and Migrant Women’s Network in Ireland, hopes to mark it’s tenth anniversary this year with the introduction of new legislation offering explicit legal protection against FGM in Ireland, while also making it a criminal offence to take a child out of Ireland to have this barbaric procedure performed in their family’s native country.
According to the Department of Justice, Equality and Law Reform, the Non-Fatal Offences Against the Person Act 1997 criminalises the practice of FGM in Ireland. However, many are concerned that this legislation is not sufficient to protect the 11,500 women and girls residing in Ireland from communities that widely practice FGM.
The Department of Health is planning to bring newly drafted legislation specifically banning FGM to the Dail in the New Year. Scope was told that the new Bill will make illegal the sending or taking of these children to another country for FGM, a scenario not covered by the 1997 Act, which may also be flawed in terms of outlawing possible cases of FGM in Ireland.
For example, it is not clear whether a defense of consent could be pleaded in a case of FGM under the 1997 Act. Adolescent girls and women very often agree to undergo FGM because they fear the non-acceptance of their communities, families and peers. Or, in the case of a minor, that her parents had given consent on her behalf.
A spokesperson for the Department of Health stresses that Minister Mary Harney is committed to publishing the new FGM legislation. But with the country facing into a general election and the economy in disarray, genuine concerns abound that the promised new laws may be lost in the ensuing political quagmire.
Alwiye Xuseyn
“This legislation is very important to our work,” says Alwiye Xuseyn, Migrant Women's Health Officer, AkiDwA. “We are putting all our eggs in one basket, and that basket is this new legislation. It will support our work with health care professionals and the practicing community to protect children and women at risk.
“There are a lot of women from practicing communities living in Ireland and we need to educate them and their community that genital mutilation is not what we should want for our daughters.
“To do this we need to get the help of health professionals and educators in Ireland. We need to have this legislation to show them that it is a real problem in Ireland, that our Government recognises the real risk to our children; that they must help.”
Dr Andrea Nugent, a consultant obstetrician and gynaecologist at Dublin’s Coombe Hospital and former course director of the MSc in women’s health at the RCSI, agrees that having legislation would bring this harrowing issue to the forefront.
“Right now FGM it is very much an undercover topic. It is an issue that most of us are unfamiliar with in Ireland. Often our patients will never disclose that they have had this procedure done, for fear of being harshly judged, or maybe it is a cause of embarrassment, or perhaps they don’t even know that they are any different from other women because they were mutilated as such a young age
“We have to protect women and girls of practicing communities in Ireland from being taken back to their country of origin to have this harmful procedure done to them, or even to have it done within the bounds of Ireland.”
Dr Nugent is not aware of any cases of FGM
Comfort Momoh
Dr Comfort Momoh, an international expert on FGM, who established the African Well Woman’s Clinic at Guy's & St Thomas's Hospital in London, says she sees over 400 women and girls every year at her clinic with FGM related problems such as flash backs, memories, recurrent urinary infection and difficulties during pregnancy and childbirth. 
“Obviously in summer we get really anxious,” she adds “All activists and professionals working around FGM get anxious because this is the time that families take their children back home. This is the time when all the professionals need to be really alert.”
“My fear is that what is happening in the UK will eventually happen over here,” cautions Dr Nugent. “Right now in Ireland there is nothing to stop a parent taking their young daughter back to their native country to have this done. There is no specific legislation to stop them arranging these “cutting parties” in Ireland. I think if and when that penny drops and people realise there are legal loopholes that could allow them to escape prosecution; it could become very dangerous for the girls in Ireland. The new legislation must be introduced without further delay.”
While this new law is important, several groups including AkiDwA, the Women’s Health Council and the Children’s Rights Alliance in Ireland believe it must be presented as a protective measure which should be promoted through a delicate balance of law enforcement, public education, and dialogue in order to protect children and future generations of women.
AkiDwA sees the medical profession as having a key role in this effort, both as change agents in attempting to convert advocates of FGM, but also as doctors capable of responding effectively to the consequences of FGM in women presenting to their services.
However, interviews and workshops run by AkiDwA revealed that these women felt unable to articulate the significant and enduring health impacts of FGM to service providers they encountered.
To address this, AkiDwA commenced an FGM health project in 2008 examining the very specific and urgent health-care needs of women who have undergone FGM and who now reside in Ireland. It soon became apparent that there were few resources on this issue for Irish health-care professionals.
This led to a successful collaboration between the Dr Nugent, her RCSI MSc Women's Health students and AkiDwA, to compile the first ever Irish handbook on FGM entitled “Female Genital Mutilation: Information for Health-Care Professionals Working in Ireland”.
This “tool-kit” was launched in January 2009 and almost 2,000 copies of the handbook have been distributed in Ireland and internationally. AkiDwA has just received funding for a second print run.
Dr Nugent explains: “On the masters course we have a broad mixture of students who are GPs, gynaecologists obstetricians and midwives. They each approached the subject of FGM from different angles and brought a real multidisciplinary aspect to the document.
“FGM is not well known in Ireland. In fact, about 75 % of the course students had never heard of it, or had heard of it in passing but didn’t fully understand the repercussions for the woman or for their medical practice.
“We wanted to make the kit very streamlined so that if you had a patient in front of you, you could access it online and it would address the very immediate issues and then give you the reference for future referral should you need it.”
The resource pack also contains a pronunciation guide and terms in the specific languages of countries where FGM is practiced; a break-down of gynaecological, obstetric, psychological and health issues; a map of FGM prevalence across Africa, and a removable image sheet designed to be used with a patient to illustrate FGM typologies.
To date, over 560 health-care professionals have attended FGM training organised by AkiDwA, including classes held in the Dublin maternity hospitals.
Dr Andrea Nugent
“It is so important to understand the intricacies of dealing with this problem,” says Dr Nugent. “A doctor needs to be able to approach it delicately and in an appropriate manner. If you believe that your patient may have been subjected to FGM it is a good idea to ask. Most people don’t have a problem if you introduce the subject by saying: ‘I understand in your country the rates of female circumcision are high, has that happened to you or do you know?’ There will be times that the patient does not know this has happened to them.
“It’s also important that when you have girls from these practicing communities who come home from their holidays and are having pelvic or genital pain, to ask if anything like this has happened to them.”
Service providers, encountering the topic of FGM for the first time, may have quite an initial emotional reaction towards FGM.
“We can be shocked by a lot of things that we come across day by day in the medical profession but it is very important not show that disapproval or judgement in your expression or in your attitude.   This type of behaviour will only push the patient away. They need to feel like there are open lines of discussion available for them to discuss their problem,” Dr Nugent advises.
The health problems a girl can experience are largely dependent on the severity of the procedure: girls and women who undergo more extensive ‘cutting’ in type II and type III (the latter includes infibulation), are likely to experience more severe health complications, but health consequences for type I have also been widely reported.
When infibulation (Type III) is performed, the opening left in the genital area is too small for the head of a baby to pass through. Failure to reopen this area can lead to death or brain damage of the baby, and death of the mother.
A study published in 2006 by the World Health Organization (WHO) found that women who have who have been subjected to Type III FGM have on average 30% more cesarean sections and there is a 70% increase in suffering postpartum haemorrhage.
Researchers also found there was an increased need to resuscitate babies whose mother had had FGM (66% higher in women with FGM III). The death rate among babies during and immediately after birth is also much higher for those born to mothers with FGM: 15% higher in those with FGM I; 32% higher in those with FGM II, and 55% higher in those with FGM III).
“It is quite common for women with FGM not to access antenatal services in a timely fashion, or to go through their pregnancy without a vaginal exam. It would not be uncommon that the obstetric or midwifery staff would not know that a woman has had this procedure until time of delivery. There is anecdotal evidence of this even in Irish hospitals. It is not frequent, but it has happened”, says Dr Nugent.
In these cases experienced surgeons should be consulted according to the injury so that the patient can be opened for delivery. Medical representatives bodies in Ireland, the UK and abroad stipulate that the woman must not be reinfibulated.
AkiDwA has plans to develop a multi-disciplinary network of counsellors and doctors who are appropriately trained to help women with FGM. At present, there is an informal arrangement with the Rotunda Hospital, where they have referred women with FGM to be defibulated, either prior to delivery or as a life choice.
“Communities that practise FGM often believe they are doing the best for their daughters. There are often pressures from home within some practicing communities that could facilitate its continuation in Ireland,” cautions Dr Nugent. “We need to develop sensitive and effective intervention strategies to support parents to abandon the practice. That’s why I’m really proud of the work that AkiDwA has done to increase awareness of a very difficult subject, and I do believe that awareness around FGM is increasing in Ireland. We may yet see a formal training course on FGM in our medical schools in the future.
“As with most things, only when we end the negativity of silence around a difficult subject,  can positive changes come about.”

(Author's note: since this article was published in early January, the now former Minister for Health Mary Harney presented the Criminal Justice (Female Genital Mutilation) Bill 2011 to Seanad √Čireann on Tuesday 18 January. This is a very welcome initial stage towards new legislation.  But there is still a long way to go before the Bill can be enacted into law (four more stages in the Seanad and then four additional stages in the Dail). Hopefully the new Government will deal with this important legislation expediently.


Why is FGM practiced?
 
The origin of FGM are largely unknown, but the practice predates contemporary world religions. Among communities that practise FGM, the procedure is a highly valued ritual, whose purpose is to mark the transition from childhood to womanhood.
The function of this practice, whether mild or severe, is ultimately to reduce a woman's sexual desire, and so ensure her virginity until marriage.
The more extensive procedure, involving stitching of the vagina, has the same aim, but reducing the size of the vagina is also intended to increase the husband's enjoyment of the sexual act.
Certain communities carry out FGM for religious reasons, believing that their faith requires it; this is particularly true of Muslims who adhere to the practice. Other communities consider female genitalia to be ugly, offensive or dirty, and thus the removal of the external genitalia makes a woman more hygienic and aesthetically pleasing.
Some even subscribe to the absurd notion that the clitoris contains powers strong enough to cause harm to a man’s penis or to damage a baby during childbirth.
This cruel practice persists today - even in African countries where recent legislation has made it illegal - primarily because of the strongly held belief that a girl is not marriageable if she has not undergone FGM, which has serious impacts on her future financial and social status.


WHO FGM Classification:


Type I
Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
Type II
Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
Type III
Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).
Type IV
All other harmful procedures to the female genitalia for non‑medical purposes, e.g. pricking, piercing, incising, scraping and cauterisation.


Prevalence

The World Health Organization estimates that between 100 and 140 million women worldwide have undergone female genital mutilation (FGM), and three million girls are at risk of FGM in Africa annually. This equates to 6,000 women and girls undergoing FGM daily in the world.
The European Parliament estimates 500,000 girls and women living in Europe are suffering lifelong consequences of FGM.
A 2007 study by the UK organisation FORWARD estimated that nearly 66,000 women with FGM were residing in England and Wales in 2001. The study speculated that this number would likely increase in the years thereafter. The study also found that nearly 21,000 girls in England and Wales aged eight and younger were at risk of FGM, and 11,000 of this cohort were likely to have already undergone some type of FGM.


Poor level of FGM awareness among doctors

A groundbreaking study in Spain identified a poor level of awareness among primary health care professionals in respect of female genital mutilation (FGM). Less than 40% correctly identify the typologies and less than 30% know in which countries it is practiced - in spite of the fact that 82% of them attend to a sub-Saharan African population, especially Senegal and Gambia, where this practice is performed on 20% and 80% of the female population, respectively. What is more, 18% of doctors showed no interest.
This project, carried out by the Interdisciplinary Group for the Prevention and Study of Detrimental Traditional Practices from the Autonomous University of Barcelona (AUB), shows that the cases of FGM detected in primary health care during a three-year period have tripled, while awareness by health care professionals has not increased proportionally.

International Day of Zero Tolerance

The United Nations has designated 8 February as the "International Day of Zero Tolerance of Female Genital Mutilation".
Increasingly, the international community is identifying FGM as a harmful traditional practice and a violation of the fundamental human rights of girls and women. Global efforts to bring an end to the custom of female genital cutting are on the rise, with many nations putting in place legislation against the practice, and a number of international organisations making the elimination of FGM a priority.
END FGM is a European campaign, led by Amnesty International Ireland, working in partnership with a number of organisations in EU member states.
By lobbying EU institutions, the campaign is committed to ensuring that Europe adopts a definitive strategy to end FGM and provide protection to women and girls who flee their countries for fear of being mutilated.