Sincere thanks and appreciation is expressed to the staff and students of the Edna Adan Maternity and Teaching Hospital who collected the data and recorded their findings on the Prenatal Charts following the physical examinations of the women attending the Prenatal Clinic.
Sincere appreciation is expressed to the Midwives and Doctors who provided Prenatal Care to the women and who supervised the students during their rotation in the department.
Sincere appreciation is expressed to the Administrative staff of the Hospital who undertook the tedious task of typing the data that had been collected by the midwives and student nurses and which had been recorded in the individual patient charts.
Sincere thanks goes also to Amal Ahmed Ali who provided much appreciated support in editing the draft document.
The tabulation and analysis of the data collected could not have been carried out without the valuable assistance of Dr. Emma Watkins of Kings College Hospital, Denmark Hill, London, to whom sincere thanks is being expressed.
According to the definition of the World Health Organization (WHO), Female Genital Mutilation FGM comprises 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 and does not include medically prescribed surgery or that which is performed for sex change reasons. It is practiced in more than 20 countries throughout Africa, the Middle East and Asia, and within immigrant populations throughout the world with prevalence rates ranging from 5-99%. Its practice can be found among all religious, ethnic and cultural groups and across all socioeconomic classes. It is estimated that up to 130 million women and girls have already been subjected to some form of FGM and 2 million more are expected to experience it each year.
Female Genital Mutilation (FGM), also known as Female Circumcision (FC), or Female Genital Cutting (FGC), is a universal practice that results in many health-related and life threatening complications. It also has other physical and psychological effects that do great harm to the wellbeing of women and children who have had it performed on them.
In the countries where most or a large number of women have been mutilated, the medical complications that result from these practices place a heavy burden on the health services of these countries.
Procedures vary throughout the world but the WHO classifies FGM2 into four types as follows:
Type 1: Excision of the prepuce with or without excision of the clitoris.
Type 2: Excision of the clitoris with partial or total excision of the labia minora.
Type 3: Excision of part or all of the external genitalia and stitching together of the exposed walls of the labia majora, leaving only a small hole (typically less than 5cm) to permit the passage of urine and vaginal secretions. This hole may need extending at the time of the menarche and often before first intercourse.
Type 4: Unclassified, covers any other damage to the female genitalia including pricking, piercing, burning, cutting or introduction of corrosive substances.
Female genital mutilation is a widespread practice that is carried out on young girls between the ages of 5 and 10 years, and in some countries on grown women as well. Unlike male circumcision, female circumcision is not a Religious obligation required by Islam, Christianity, or any of the other known religions; The practice is nevertheless a cultural tradition. It is practiced mainly in Africa and in some Asian countries. At one time it is said to have even existed in Europe before it was abolished in that continent some centuries ago.
In recent years because of immigration and population movements, the practice is emerging among refugee populations in Europe and North America where the medical and obstetrical complications that mutilated women and girls are seeking treatment for is causing a lot of concern among health-care providers in Western countries. This concern is expressed through the constant attention FGM receives from international health and human rights organizations as well as from the world media.
Prior to this present study that is being reported on, there had been very few studies conducted in the past, or studies had been on a small number of women.
Some of the most accurate early data on FGM comes from Fran Hosken3 who in 1982 compiled statistics from her many years of studying FGM in Africa. Between 1995 and 2002 the Demographics and Health Surveys published data compiled by questionnaire from 16 countries, but Somaliland and Somalia were not included. Countries that have had repeated data collected have shown small declines in prevalence and a trend to less severe forms of mutilation4. There are a number of published studies from African countries, (not including Somaliland), in particular Nigeria, which have estimated FGM prevalence, but most have involved small numbers and have only been carried out over short periods
In 1998 a national survey by the Ministry of Health in Somalia stated a 96% prevalence rate. In 1999 Care International studied Somaliland and stated that it was universal, with 91% undergoing the most severe form, Type 3. A Swedish study published in 1991 questioned 290 Somali women living in Sweden and found that 100% had FGM, with 88% being Type 3 despite a relatively high socio-economic level, and the majority was willing to perform FGM on their daughters due to religious reasons. A recent study by the WHO and UNICEF looking for the first time, into HIV prevalence also asked women about their FGM status. The study included 769 women and found that 98% had undergone Type 3 circumcision.
The United Nations and other humanitarian organizations consider FGM a violation of human rights. As early as 1979 the WHO recommended, at an international conference, that the practice should be eradicated and in 1993 the World Health Assembly called for abolition of the practice. Consequently, most countries have strict laws forbidding the practice.
Female Genital Mutilation is occasionally reported to be practiced by a limited few in Oman; Saudi Arabia; United Arab Emirates; Yemen; and by even fewer in certain communities in Indonesia; Malaysia; India and Pakistan.
Female Genital Mutilation is reported to exist in many African countries, in some it is performed on all or most women while in others it may be performed only on some women belonging to certain ethnic groups.
The countries where FGM is reported to be practiced with varying applications of Types and different prevalence rates are:
Benin; Burkina Faso; Cameroon; Central African Republic; Chad, Democratic Republic of the Congo, Djibouti, Egypt, Eritrea, Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, Somalia, Somaliland, Sudan, Tanzania, Togo, Uganda.
It has long been accepted that FGM is ubiquitous in Somaliland but accurate data has been lacking. Anecdotal evidence suggests that the procedure was commonly performed on girls between the ages of 4 and 11 and that 95–100% of women had undergone the procedure, the majority of whom having been subjected to the most severe form of mutilation. The study included in this present report shows that 97 % of the Somaliland women receiving antenatal care at Edna Adan Hospital have undergone FGM. In Somaliland the women refer to their procedure by two names, the Sunna and the Pharaonic. The Sunna correlates with Type 1 and 2 but also involves stitching of the anterior part of the genitalia to varying extent. The Pharaonic correlates with Type 3.
Many successful awareness campaigns have been run in Somaliland since 1997 and as a result more Somalilanders are willing to openly discuss the topic of FGM and are becoming increasingly concerned about the health risks associated with the procedure.
The day of the FGM is considered an important event but it is kept secret from the pre-menarche child, and then sprung upon her once the necessary preparations have been made. Senior female members of the community, relatives, traditional birth attendants (TBA’s) or occasionally healthcare workers may be called upon to carry out the procedure.
No anesthesia is used while this very sensitive part of the female body is being brutally cut and manipulated, except when the operation is being performed by a health professional who has access to anesthetics and who the required knowledge in their use.
The age at which female genital mutilation is performed varies from country to country and according to the type of mutilation being done. The SUNNA is generally the type that is performed at a very young age and may be carried out soon after birth, during the first week of life or at any time before the Menarche. In the case of EXCICION and INFIBULATION when more tissues are to be removed which entail more manipulations, the child is allowed to grow older so that the tissues intended for excision are also given a chance to grow. This gives the operator a better pinch or grip. According to the findings of our survey, it was found that the usual age when Excision and Infibulations are performed is between seven and nine years of age.
In some cases, instead of suturing together the raw edges of the wound, these are held together with thorns that are inserted on opposite sides of the wound and then laced together with thread and left in place for seven days or until the tissues of the wound have had time to fuse together. This type of infibulation is often practiced by nomads and agro–pastoralists.
Since bleeding will occur and since there will be some secretions for some days, the family usually finds an old mat or floor covering that can later be discarded.
Sometimes sand is placed on the mat under the buttocks of the child in order to absorb blood and other secretions.
In the case of more affluent or educated families, they may be more likely to be aware of the risks of infection and usually such families would have clean sheets and also gauze pads to absorb any blood or secretions from the wound.
The child is made to squat on a stool or mat facing the operator at a convenient height that offers the operator a good view of the parts to be handled. This is important for the operator is often an elderly person whose sight may be impaired and who may find bending over difficult.
Understandably, it is vital for the child to be held as still as possible in order to avoid inflicting cuts other than those intentionally being carried out for the purpose of Infibulation. For this, adult helpers grab and pull apart the legs of the little girl. Usually, two persons grab one leg each and also hold down her hips; a third person holds back the head and torso. To prevent kicks, the child’s legs are held back by tying a rope to each of her ankles which is then tied to her thighs thus keeping each leg in a tightly flexed position in what can roughly be described as a modified and forced Trendenlenberg.If available, this is the stage at which a local anesthetic would be used.
The element of speed and surprise is vital and the operator immediately grabs the clitoris by pinching it between her nails aiming to amputate it with a slash. The organ is then shown to the senior female relatives of the child who will decide whether the amount that has been removed is satisfactory or whether more is to be cut off. After the Clitoris has been ‘satisfactorily’ amputated, and also after the female relatives have ‘ululated’ to let those outside know that the business at hand is progressing well, the operator can then proceed with the total removal of the labia minora and the paring of the inner walls of the labia majora . Since the entire skin on the inner walls of the Labia Majora has to be removed all the way down to the perineum, this becomes a very messy business as the child who is by now screaming and struggling is also bleeding profusely making it difficult for the operator to hold with bare fingers and nails the slippery skin and the parts that are to be cut or sutured together.
It needs to be stressed here that it is important for the wound to heal by first intention not only to protect the child from a repeat operation, but also mainly to preserve the popularity of the operator who would otherwise acquire a bad reputation and also would lose future potential clients if the wounds that she handles do not heal well. Having made sure that sufficient tissue has been removed to permit the desired fusion of the skin, the operator pulls together the opposite sides of the labia majora, ensuring that the raw edges where the skin had been removed are well approximated. The wound is now ready to be stitched or for thorns to be applied.
If a needle and thread are being used, close tight sutures will be placed to ensure that a flap of skin covers the vulva and extends from the Mons Veneris to the Perineum and which, after the wound heals, will form a bridge of scar tissue that will totally occlude the vaginal entroitus. A small hole having the diameter of a matchstick will be left un-stitched in order to permit the flow of urine and vaginal secretions. If thorns are being used, an equal number would have been inserted into each side of the labia majora, and a string would then be used to pull the thorns together and thus bring the raw edges of the labia majora together. The string would be wound in the same way that sports shoes with hooks are laced. If the female genital cutting is being done by a person who has some knowledge of dressing wounds, they would apply regular medical disinfectants.
After the stitching, a raw egg is broken over the wound, which is then sprinkled, with whatever herbs, sugar or concoction that were prepared according to the dictates of the local custom, or the practice of the ‘operator’. This concoction, consisting of egg, herbs, sugar, and the blood of the child, would all clog together and form a crust over the sutures or the strips of cloth holding the thorns together. One can only wonder why more girls do not develop infections after this rich culture medium for bacteria has been placed between the legs of these little girls. In order to prevent leg movement, the child’s legs are bound together from the hips down to her toes and the child is then made to lie on her side.
No dressing is used and the legs are kept together for a week after which the leg bindings are slightly loosened and the child allowed taking small steps. The leg bindings will be removed altogether after a further week. To ascertain that the urethra has not been accidentally closed, either by a blood clot or suture, the child is encouraged to urinate a few hours after the operation. Whether sutures or thorns were inserted, these will be removed on the seventh day but only after the operator is satisfied that the two sides of the labia majora have fused together and that the remaining hole for urination is not wider than three to five millimeters in diameter.
The closure of the introitus must be reopened at the time of marriage so that the woman is able to have sexual intercourse. The opening up of the infibulation occurs as part of a ceremony and in the presence of female members from the bride and groom’s families to verify that the bride is a virgin at the time of marriage. The opening of the infibulation is performed by a senior female member of the community, a TBA, or in a hospital by medical staff. Occasionally, the husband forcibly performs penetration and bursts through the scar of the infibulation.
FGM puts children at risk of life threatening complications at the time of the procedure as well as health problems that remain with her for life. They may suffer bleeding at the time of the procedure or develop severe infection, both of which can lead to death if not treated promptly. Those who do not develop life-threatening complications will still suffer from severe pain and trauma.
The procedure also permits the transmission of viral infections such as hepatitis which can lead to chronic liver diseases and even HIV. The women may suffer complications such as recurrent infections, pain and obstruction associated with urination and they are at higher risk of painful menstruation and intercourse, pelvic infection and difficulties in becoming pregnant. Retention of urine and recurrent infections often require repeated hospital admissions and some women carry a risk of developing nephritis. The development of cysts and keloids at the site of the scar are very common, often causing embarrassment and marital problems, and usually require surgery for removal.
During pregnancy there are many further complications that may occur as a direct result of the FGM. Labour may become obstructed and if early medical intervention is not provided this may lead to the death of both baby and mother. WHO estimates that many women giving birth die in the process, simply as a result of FGM 19. If the mother and baby survive there is the risk of damage to the vagina leading to the formation of fistulas into the bladder or bowel, which cause constant incontinence as a result of a vessico-vaginal fistula or recto-vaginal fistula. Women in this condition are often rejected by their family and become social outcasts. During the seven years that the Edna Adan Hospital has been functional, the fistulae of over 100 women have been surgically repaired. Apart from the many physical complications, the girls and women experience considerable psychological problems including depression, anxiety and post-traumatic stress disorder. These psychological problems are exacerbated at the time of marriage and often lead to increased distress and fear of intercourse. If de-infibulation is performed the woman is again exposed to the life threatening complications of sepsis and bleeding, and the transmission of chronic infections such as HIV and Hepatitis and also damage to the urethra if, as is common, the operator makes an error when performing the cut.
Considering the clumsy and un-hygienic conditions under which female genital mutilation is usually performed, complications are frequent and numerous and can be classified in the order in which they are likely to occur.
These cuts may involve the vagina, urethra, anus and thighs.
As a result, quite a few children are taken to hospitals for the control of hemorrhage, or for the repair of severe lacerations.
This the families resist because they fear that if the opening is too wide it may not be sufficient proof that their daughter is a virgin when her time comes for her to get married.
In recent years and since the HIV/AIDS pandemic, likelihood of transmission of the AIDS virus has become added to the long list of complications associated with female genital mutilation. The risk is made real because the traditional healers who perform circumcisions do not know the dangers of using unsterilized instruments that have previously been used on different individuals who might have been carriers of the AIDS virus.
The reasons that drive the practice of FGM lie deep within tradition and cultural heritage and are complex and difficult to determine. Although there is variation between societies there are common themes. FGM is often wrongly believed to have a religious origin or to be a requirement of certain religions but this is not the case.
In the majority of societies FGM is believed to preserve the woman’s virginity before marriage and ensures fidelity during marriage. Other common beliefs include that it is hygienic, aesthetically pleasing or increases fertility.
For many women it is part of social integration and the mutilating process is accepted in return for benefits such as the promise of acceptance in society and the improved prospect of marriage. Older women often believe they have benefited from FGM and that it has been essential to their identity. By the same reasoning they allow it to be performed on their daughters fearing that failure to do so may bring them suffering and social isolation.
Understanding these complex, multifaceted thought processes within societies is key to the design of successful, culturally acceptable and correctly targeted eradication campaigns.
The International Campaign against FGM has a long and difficult history. Advocacy and resistance started with individual health professionals from practicing African countries working in their communities. Their efforts are to be commended as they worked in unreceptive environments with little support. However there are not many records of these efforts and the extent of their impact in not known.
Although the UN support for the eradication of FGM is now strong and active, it was slow in coming. Lack of knowledge on the subject first prevented UN agencies from addressing the issue. When awareness finally came to the UN about the extent of the practice and the serious health and psychological effects that result from it, they recognized it as a major Human rights issue. Conferences were held, studies were commissioned and discussions were finally opened on the topic. However, the mainly European representatives chairing these discussions did not understand the deep cultural ties that propagated the practice and they were unprepared for the resistance they faced by recently decolonized African nations who saw the attention on the issue as another intrusion. There were exceptions however. East African countries, including Somalia where the most severe forms of FGM are practiced and who had more active campaigns were more appreciative of UN involvement. After these first rounds of conferences around the 1980s, it was realized even talking about the topic was sensitive, so immediate abolition was impossible. While mandates condemning Female Circumcision, as it was know then, were taken, in terms of actual field work, the UN took the approach of funding local efforts. These local efforts concentrated on the areas of education and advocacy. Training was needed for the health professionals dealing directly with the victims. Governments were lobbied to create policies against FGM or if such policies already existed to implement them proactively. The general public was educated on the subject, and this was the most important work that permitted the timid steps towards change to be achieved. The struggle continues to this day with varying degrees of success. Complete eradication has not been achieved, nothing close has even been attained, but the topic is more openly discussed now than it was thirty or forty years ago.
In March 1977, during the formation of the Somali Women’s Democratic Organization (SWDO), Edna Adan Ismail was the first Somali person to publicly denounce FGM and pioneered the campaign for its eradication in Somalia and in Somaliland. From that time she has campaigned against FGM at many important occasions, including during the WHO Seminar in Khartoum in 1979 on the Mental and Physical Complications of FGM; in 1980 during the Mid-Decade Conference for women in Copenhagen; in Lusaka in the same year; In Dakar in 1984 when she co-founded and was elected the Vice-President of the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children; In 1986 in EMRO Egypt; 1987 in Addis Ababa and the lobbying of the Organization of African Unity. During the Beijing Women’s Conference in 1995 and between 1988 and 1997 when she tirelessly along with international colleagues, lobbied WHO/UNICEF and every Human Rights Organization.
That first gathering of SWDO was a golden opportunity to address the future leaders of women in their respective regions of the country and Edna Adan took full advantage of the opportunity. It was the first time the problem of FGM was spoken about in public in Somalia/Somaliland. Thereafter Edna Adan lectured medical students at the University of Mogadishu as well as nursing students in various nursing schools in Asia and Africa. The subject was included in the curricula of these schools and future health professionals all finished their education with knowledge of the harmful effects of FGM.
In the early 1980’s research into the physical, psychological and sociological aspects of FGM was carried out by the Somalia academy of arts and Sciences. In 1988 the government campaigned to eradicate the practice on health and religious grounds. The SWDO continued their struggle and joined with the Italian Association for women and development (AIDOS) in 1987 and over the following years founded a campaign based on health complications fearing that one based on human rights would fail. Both campaigns collapsed in 1991 with the overthrow of Siyad Barre and of the disintegration of the government in Somalia.
In 1997, at the time when Edna Adan Ismail was WHO Representative in the Republic of Djibouti, UNICEF requested her to assist to obtain the approval of the government of Somaliland for a seminar to be held in Hargeisa to launch the first seminar to revive the campaign to eradicate FGM. The seminar was approved and held and a national committee and a regional task force were established to develop formal policies. This work continues and at the same time a variety of NGO’s and women’s groups also run their own eradication campaigns.
There have been encouraging signs that the awareness campaigns are having the desired effect. A recent Save the Children publication on child rights in Somaliland found that most girls and boys, and some care givers, community leaders and government officials, point to the harmful traditional practices of FGM as the most negative aspect of Somaliland society and culture.
Education and the empowerment of women brought about by eradication campaigns are changing the views of Somalilanders on FGM, but it is only by the implementation of audits like this one conducted at the Edna Adan Hospital that the rate of change can be accurately recorded and evaluated. In a society where the practice is almost universally accepted change will occur slowly for as long as people fear discrimination for choosing to break with tradition.
The Edna Adan Maternity and Teaching Hospital is a major player in the campaign against FGM. The next pages provide information about the hospital and its vital role in this work.
The Edna Adan Maternity and Teaching Hospital confronts the effects and complications of FGM almost on a daily basis. Cases include children who have been mutilated hours and sometimes days before being brought to the hospital and who are still bleeding quite heavily or unable to pass urine because of their new stitches. The severest case of a mutilated child seen at the hospital was one where the child had been so badly cut, that there was virtually no skin to suture together to stop the gushing blood coming from her little body.
Common cases also include newly married girls and women just de-infibulated and suffering from bleeding, infection or just plain pain. Also, women in Labour for much longer than they need be because scarring due to FGM prevents the birth canal from dilating properly. Some of those women end up with third degree lacerations and other post natal complications.
Edna Adan has been dealing with cases of this nature in her 50 years of midwifery experience and has been engaged in a life-long struggle to see the end of this practice. With the establishment of her maternity hospital and with the still much needed services to deal with FGM, It has become essential for the hospital to lead the campaign. it is fast becoming a repository of all information relating to FGM in Somaliland and the region. The hospital has started an auditing process to have baseline data about the prevalence of FGM and the survey in this report is the first data to come out of that auditing initiative and it is believed to be the first of its kind in Somaliland. The hospital holds educational and sensitization seminars for concerned groups. At a patient level, counselling services are provided to the victims of FGM and their families. There is no other institution in the country better equipped with the experience, knowledge, facilities, and above all, dedication and sheer ‘Will’ to tackle this issue.
This study was compiled from a survey carried out on the women attending the Prenatal Clinic at the Edna Adan Maternity and Teaching Hospital in Hargeisa, Somaliland between March 2002 when the hospital was opened up to August 2006. The findings were diligently recorded on the Prenatal Charts of each woman so that the information could be compared with future findings during subsequent surveys.
The data that was obtained has provided information on the prevalence of FGM, the type of procedures that had been performed on the persons examined, the ages when the procedure had been performed on them, and details of those who had performed it on them. The data also provided an insight into what motivates the continuance of the practice and a prediction of the future risks to young girls. It is believed that the results from such a reliable audit on the prevalence of FGM would be a crucial element in achieving the goal of eradication of the practice since the information obtained can be used as a baseline data for directing future awareness campaigns and auditing their success. Finally, the data collected is of interest to the local community in Somaliland and also to medical professionals, NGO’s, International Aid agencies, women’s groups, and to all those who are fighting the practice wherever they may be in the world.
The Edna Adan Maternity and Teaching Hospital is the main site in Somaliland for holding campaigns against FGM. Its founder and director, Mrs. Edna Adan Ismail is a pioneer in the fight to end FGM in Somalia and Somaliland who started her advocacy work on the subject as far back as 1977.
Examination of the vulva of the patient as part of the physical examinations carried out on all pregnant women attending the clinic for Antenatal Care. On occasions, it was not clear whether the person had undergone any form of FGM and a confirmation was obtained from the woman herself to record whether the answer should be a ‘Yes’ or a ‘No’. If the answer was a ‘No’, it would be recorded as such and the finding was included in the number of women who had no FGM performed on them. If the answer was a ‘Yes’ then the rest of the questionnaire would be completed.
In order to ensure the uniformity of the data, a simple questionnaire was developed and printed on the Antenatal Cards of the hospital so that all women who attended the Antenatal clinic had the findings recorded on their individual patient card.
The battle for the abolition of FGM is definitely one that is too difficult to be left to individual crusaders and little old women.
It has to be fought by all and particularly by government and by professionals such as Obstetricians, Gynecologists, Pediatricians,
Nurses and Midwives who are the ones who have to deal with the serious complications caused by female genital mutilation.
These recommendations show the need for a wide, and all-encompassing approach in the fight to eradicate Female Genital Mutation. Because the practice is so pervasive, all areas of society must be targeted, simultaneously and continuously.