FEMALE GENITAL MUTILATION (FGM): AGAINST WOMEN'S HEALTH AND HUMAN RIGHTS
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FEMALE GENITAL MUTILATION (FGM): AGAINST WOMEN’S
HEALTH AND HUMAN RIGHTS
Women and Health Learning Package
Developed by The Network: TUFH Women and Health Taskforce
Second edition, September 2006
Support for the production of the Women and Health Learning Package (WHLP) has been provided
by The Network: Towards Unity for Health (The Network: TUFH), Global Health through Education,
Training and Service (GHETS), and the Global Knowledge Partnership. Copies of this and other
WHLP modules and related materials are available on The Network: TUFH website at
http://www.the-networktufh.org/publications_resources/trainingmodules.asp or by contacting GHETS
by email at info@ghets.org, or by fax at +1 (508) 448-8346.
About the author
Mohamed Moukhyer, MBBS, MSc, PhD
Assistant Professor of Public Health and Vice-Dean for Academic Affairs
School of Medicine , Ahfad University for Women
Omdurman, Sudan
Dr Moukhyer holds an MBBS and an MSc in Public Health, and received his PhD in 2005
from the Department of Health Promotion and Health Education, Maastricht University, the
Netherlands, with a focus on the health profile of Sudanese adolescents. Dr Moukhyer is
Assistant Professor of Public Health and Vice-Dean for Academic Affairs at the School of
Medicine at Ahfad University for Women in Omdurman, Sudan, and is a member of the
Management Committee of The Network: TUFH Women and Health Taskforce. His interests
include reproductive health, adolescent health, gender issues and the Family Attachment
Program.
Women and Health Learning Package: Female Genital Mutilation 1
www.the-networktufh.orgFEMALE GENITAL MUTILATION (FGM): AGAINST WOMEN’S HEALTH AND HUMAN RIGHTS Global Overview Female genital mutilation (FGM) is the term now generally accepted for traditional practices that entail removal of or injury to part of the external genitalia of girls or women. It does not include genital surgery performed for medical reasons. The exact historical origin of the FGM is still controversial, and the practice is too widespread to have one common origin (Mustafa 1996). Infibulation is commonly called pharaonic circumcision, which might point to the pharaonic era, though supporting evidence is faint. Archaeological conclusions drawn from Egyptian mummies remain controversial, but Herodotus alludes to FGM in Egypt as early as 500 BCE. He mentions it among the Phoenicians, Hittites and Ethiopians as well, a designation which would include some tribes of Sudan today (Sanderson Hosken 1979). According to Strabo, the Greek geographer, the operation was done on girls in Egypt in about 23 BCE (Hosken 1979). FGM predates Islam and is not practised by most Muslims, but it has acquired a religious dimension. Where Muslims practise FGM, religion is frequently cited as a reason. Many of those who oppose mutilation deny that there is any link between the practice and religion, but Islamic leaders are not unanimous on the subject. The Quran does not contain any call for FGM, but a few hadith (sayings attributed to the prophet Mohammad) refer to it. In one case, in the answer to question put to him by Um Attiya (a practitioner of FGM), the prophet is quoted as saying ‘reduce but do not destroy’. Mutilation has persisted among some converts to Christianity. Christian missionaries have tried to discourage the practice, but found to be too deeply rooted. In some cases, in order to keep converts, missionaries have ignored and even condoned the practice. In section 17 of Genesis, God is reported to have ordered the Prophet Abraham when he was 99 years old to circumcise himself and all the males of his tribe and their slaves as sign of alliance between God and the descendants of Abraham (Symposia 1996). According to the authors, the first woman to be circumcised was Hagir, the second wife of the Prophet Abraham. Sara, the first wife of Abraham, circumcised Hagir, who became pregnant, out of jealousy and to prevent her from having sexual intercourse. Another story mentioned that a certain Sultan, who was jealous of the dissolute life of his wives, had his entire harem excised in order to keep them faithful (Hosken 1979). All the above and the like seem to be allegations or stories that lack scientific authentication. Therefore, their status can only be fitted within the framework of mythology. It remains to say that during the 19th century there were gynaecological surgeons who performed clitoridectomies (e.g. in Europe) for allegedly medical reasons such as a cure for nymphomania, for example, or to prevent masturbation (Rushwan 1993). However, in 19th century what was known as love surgery was performed in US, which involved clitoral relocation (similar to the so-called Sunn circumcision) by removal of the prepuce with the idea that it enhances sexual pleasure by exposure of sensitive clitoral area (Symposia 1989, 1991, 1994, 1996). Women and Health Learning Package: Female Genital Mutilation 2 www.the-networktufh.org
However, the historical dimension of FGM practices could only be of relevance and
importance within the context of discussing the influence of culture and traditions prevailing
in a specific society and thus influencing the perpetuation of the practice.
Although there are different views on the origin of FGM and how it spread, it goes far back
in time, and it has been claimed that the practice dates long before Islam and Christianity in
Sudan (Thiam 1978).
As has been presented in the available literature, justification for the practice varies from one
place to another. The justification could be cultural, religious, medical, moral or a multiple of
those reasons and others. The practice is also said to be associated with illiteracy, poverty and
a low status of women.
Historically, many attempts have been made to classify and describe the different types of
FGM. Worsely (1930) described three types:
1. Introcision
2. The circumcision of women
3. Infibulation
Shandel, et al (1967) described four types in Sudan:
1. Circumcision proper
2. Different degrees of clitoridectomy, which may include removal of part or all of the
labia minora
3. Infibulation (classical Pharaonic circumcision)
4. Introcision.
Many modifications of the Shandal classification followed (including Daw 1970; Verzein
1975; Aziz 1980; Ragiya 1982; El-Dareer 1983; Thomas-Koso 1987, and Diri 1992).
The term female genital mutilation (FGM) was first used by feminists, women’s health
advocates and human rights activists, and was subsequently adopted by the Inter-African
Committee at a meeting in Addis Ababa, Ethiopia, in 1990. Since then, it has also been
adopted by the United Nations and is increasingly used by the public. Prior to its adoption,
the practice was referred to as female circumcision, a term still in common use. Female
genital cutting (FGC) is another term which is often used.
The terminology used to describe the different forms of female genital mutilation varies
widely among the population groups where they are practised and among researchers, health
personnel, health advocates and others. Removal of the prepuce has been called true
circumcision, in that it is equivalent to male circumcision. Clitoridectomy is sometimes
referred to as mild circumcision and is also known as Sunna circumcision by some Muslim
communities. However, the Koran does not recommend any form of female genital
mutilation, and it is suggested that, in order to prevent any misunderstanding that there is
such a link, the term Sunna should be discouraged. Infibulation may be termed severe
circumcision and is also known as Pharaonic circumcision in Sudan and Sudanese
circumcision in Egypt. A modified form of infibulation has been called intermediate
circumcision.
The most severe form of female genital mutilation is infibulation, or Pharaonic circumcision.
An estimated 15% of all FGM in Africa are infibulations. The procedure consists of a
Women and Health Learning Package: Female Genital Mutilation 3
www.the-networktufh.orgclitoridectomy (where all or part of the clitoris is removed), excision (removal of all or part of the labia minora), and cutting of the labia majora to create raw surfaces, which are then stitched or held together in order to form a cover over the vagina when they heal. A small hole is left to allow urine and menstrual blood to escape. In some less conventional forms of infibulation, less tissue is removed and a larger opening is left. The vast majority (85%) of FGM performed in Africa consists of clitoridectomy or excision. The least radical procedure consists of the removal of the clitoral hood. In some traditions a ceremony is held, but no mutilation of the genitals occurs. The ritual may include holding a knife next to the genitals, pricking the clitoris, cutting some pubic hair, or light scarification in the genital or upper thigh area. The type of mutilation practised, the age at which it is carried out, and the way in which it is done varies according to a variety of factors, including ethnic group, country, residence in a rural versus an urban area, and socio-economic status. The procedure is carried out at a variety of ages, ranging from shortly after birth to sometime during the first pregnancy, but it most commonly occurs between the ages of four and eight. According to the World Health Organization, the average age is falling. This is believed to be particularly true in urban areas, and it indicates that the practice is decreasingly associated with initiation into adulthood. Some girls undergo genital mutilation alone, but mutilation is more often undergone in a group, as with sisters, other close female relatives, or neighbours. Where FGM is performed as part of an initiation ceremony, as is the case in societies in eastern, central and western Africa, it is more likely to be carried out at the same time on all the girls in the community who belong to a particular age group. The procedure may be carried out in the girl’s home, in the home of a relative or neighbour, in a health centre, or, especially if associated with initiation, at a specially designated site such as a particular tree or river. The person performing the mutilation may be an older woman, a traditional midwife or healer, a barber, or a qualified midwife or doctor. Girls undergoing the procedure have varying degrees of knowledge about what will happen to them. Sometimes the event is associated with festivities and gifts. Girls are exhorted to be brave. Where the mutilation is part of an initiation rite, the festivities may be major events for the community. Usually only women are allowed to be present. Sometimes a trained midwife will be available to give a local anaesthetic. In some cultures, girls will be told to sit beforehand in cold water, to numb the area and reduce the likelihood of bleeding. More commonly, however, no steps are taken to reduce the pain. The girl is immobilized, usually held by older women, with her legs apart. Mutilation may be carried out using broken glass, a tin lid, scissors, a razor blade or some other cutting instrument. When infibulation takes place, thorns or stitches may be used to hold the two sides of the labia majora together, and the legs may be bound together for up to 40 days. Antiseptic powder may be applied, or, more commonly, pastes – containing herbs, milk, eggs, ashes or dung – which are believed to facilitate healing. The girl may be taken to a specially-designated place to recover, where, if the mutilation is part of an initiation ceremony, traditional teaching is imparted. For the very rich, a qualified doctor in a hospital under local or general anaesthetic may perform the mutilation procedure. Women and Health Learning Package: Female Genital Mutilation 4 www.the-networktufh.org
Geographical distribution and prevalence of female genital mutilation An estimated 135 million of the world’s girls and women have undergone genital mutilation, and two million girls a year, or approximately 6,000 per day, are at risk of mutilation. FGM is practised extensively in Africa and is common in some countries in the Middle East. It also occurs in parts of Asia and the Pacific, North and Latin America and Europe, mainly among immigrant communities. FGM has become a health and human rights issue in Australia, Canada, England, France, and the United States, due to the continuation of the practice by immigrants from countries where FGM is common. For more information, see the PATH website for facts about FGM (http://www.path.org/files/FGM-The-Facts.htm). FGM is reportedly practised in more than 28 African countries. It is estimated that 5.5 million children or adolescents are operated on annually, primarily in Africa. One source calculated that FGM is found in at least 20 sub-Saharan countries. However, there is a wide range of difference in the extent of the practice among and within these countries, from nearly 100% of women in Somalia and Djibouti, to less than 5% in Uganda and Zaire. In Burkina Faso, approximately 70% of women have been genitally excised, while in Ghana the figure is around 30%. In northern Sudan, 89 percent of women ages 15-49 who have never married are infibulated, but the procedure is rare in southern Sudan. There are no figures to indicate how common FGM is in Asia. It has been reported among Muslim populations in Indonesia, Sri Lanka and Malaysia, although very little is known about the practice in these countries. In India, a small Muslim sect, the Daudi Bohra, practise clitoridectomy. In the Middle East, FGM is practised in Egypt, Oman, Yemen and the United Arab Emirates. There have been reports of FGM among certain indigenous groups in Central and South America, but little information is available. In industrialized countries, genital mutilation occurs predominantly among immigrants from countries where mutilation is practised. It has been reported in Australia, Canada, Denmark, France, Italy, the Netherlands, Sweden, the United Kingdom and the United States. Girls or female infants living in industrialized countries are sometimes operated on illegally by doctors from their own communities who reside there. More frequently, traditional practitioners are brought into the country or girls are sent abroad to be mutilated. No figures are available on how common the practise is among the populations of industrialized countries. Complications of FGM Physical effects Female genital mutilation can lead to physical complications or even death. During the mutilation, pain, shock, haemorrhage, and damage to organs surrounding the clitoris and labia can occur (Bredie, et al 1945). After the mutilation, urine may be retained and serious infections can develop. Use of the same instrument on several girls without sterilization can cause the spread of HIV/AIDS. More commonly, chronic infections, intermittent bleeding, abscesses and small benign nerve tumours can result from clitoridectomy and excision, causing discomfort and extreme pain. Women and Health Learning Package: Female Genital Mutilation 5 www.the-networktufh.org
Infibulations can have even more serious long-term effects including chronic urinary tract infections, bladder stones, urethra and kidney damage, reproductive tract infections resulting from obstructed menstrual flow, pelvic infections, infertility, excessive scar tissue, keloids (raised, irregularly shaped, progressively enlarging scars) and dermoid cysts. First sexual intercourse can only take place after gradual and painful dilation of the opening left after mutilation. In some cases, cutting is necessary before intercourse can take place. In one study carried out in Sudan, 15% of women interviewed reported that cutting was necessary before penetration could be achieved. Some new wives are seriously injured by unskilful cutting carried out by their husbands. A possible additional problem resulting from all types of female genital mutilation is that lasting damage to the genital area can increase the risk of HIV transmission during intercourse. During childbirth, existing scar tissue on excised women may tear. Infibulated women, whose genitals have been tightly closed, have to be cut to allow the baby to emerge. If no attendant is present to make this cut, perineal tears or obstructed labour can occur. After giving birth, women are often re-infibulated to make them ‘tight’ for their husbands. The constant cutting and re-stitching of women's genitals with each birth can result in tough scar tissue in the genital area. The secrecy surrounding FGM, and the protection of those who perform these procedures, make collecting data about complications resulting from mutilation difficult. When problems do occur, they are rarely attributed to the person who performed the mutilation. They are more likely to be blamed on the girl’s alleged ‘promiscuity’ or the fact that sacrifices or rituals were not carried out properly by her parents. Most information is collected retrospectively, often a long time after the event. This means that one has to rely on the accuracy of the woman’s memory, her own assessment of the severity of any resulting complications, and her perception of whether any health problems were associated with mutilation. Some data on the short- and long-term medical effects of FGM, including those associated with pregnancy, have been collected in hospital or clinic-based studies, and these have been useful in acquiring knowledge of the range of health problems that can result. However, the incidence of these problems and of deaths as a result of mutilation cannot be reliably estimated. Supporters of the practice claim that major complications and problems are rare, while opponents of the practice claim that they occur frequently. Sexual problems Genital mutilation can make first sexual intercourse an ordeal for women. It can be extremely painful and even dangerous if the woman has to be cut open; for some women, intercourse remains painful. Even where this is not the case, the importance of the clitoris in experiencing sexual pleasure and orgasm suggests that mutilation involving partial or complete clitoridectomy would adversely affect sexual fulfilment. Clinical considerations and the majority of studies on women’s enjoyment of sex suggest that genital mutilation does impair women’s sexual pleasure. One study, however, found that 90% of the infibulated women interviewed reported experiencing orgasm. The mechanisms involved in sexual enjoyment and orgasm are still not fully understood, but it is thought that compensatory processes, some Women and Health Learning Package: Female Genital Mutilation 6 www.the-networktufh.org
of them psychological, may mitigate some of the effects of removal of the clitoris and other sensitive parts of the genitals. Psychological and social problems The psychological effects of FGM are more difficult to investigate scientifically than the physical ones. A small number of clinical cases of psychological illness related to genital mutilation have been reported (Baasher 1979). Despite the lack of scientific evidence, personal accounts of mutilation reveal feelings of anxiety, terror, humiliation and betrayal, all of which would be likely to have long-term negative effects. Some experts suggest that the shock and trauma of the operation may contribute to behaviour described as ‘calm’ and ‘docile’, considered positive in societies that practise female genital mutilation. Festivities, presents and special attention at the time of mutilation may mitigate some of the trauma experienced, but the most important psychological effect on a woman who has survived FGM is the feeling that she is acceptable to her society. She has upheld the traditions of her culture and made herself eligible for marriage, often the only role available to her. In fact it is possible that a woman who did not undergo genital mutilation could suffer psychological problems as a result of rejection by society. Where the FGM-practising community is in a minority, women are thought to be particularly vulnerable to psychological problems, caught as they are between the social norms of their own community and those of the majority culture. Why FGM is practised Cultural identity Custom and tradition are by far the most frequently cited reasons for FGM. Along with other physical or behavioural characteristics, FGM defines who is in a group. This is most obvious where mutilation is carried out as part of the initiation into adulthood. Jomo Kenyatta, the late President of Kenya, argued that FGM was an integral part of initiation and an essential part of being Kikuyu, to such an extent that ‘abolition...will destroy the tribal system’. A study in Sierra Leone reported a similar feeling about the social and political cohesion promoted by the Bundo and Sande secret societies, both of which carry out initiation mutilations and teaching. Many people in FGM-practising societies, especially in traditional rural communities, regard FGM as so normal that they cannot imagine a woman who has not undergone mutilation. Others are quoted as saying that only outsiders or foreigners are not genitally mutilated. A girl cannot be considered an adult in an FGM-practising society unless she has undergone FGM. Gender identity FGM is often deemed necessary in order for a girl to be considered a complete woman, and the practice marks the divergence of the sexes in terms of their future roles in life and marriage. Women and Health Learning Package: Female Genital Mutilation 7 www.the-networktufh.org
The removal of the clitoris and labia, viewed by some as the ‘male parts’ of a woman’s body, is thought to enhance the girl’s femininity, which is often synonymous with docility and obedience. It is possible that the trauma of mutilation may have this effect on a girl’s personality. If mutilation is part of an initiation rite, then it is often accompanied by explicit teaching about the woman’s role in her society. Control of women’s sexuality In many societies, an important reason given for FGM is the belief that it reduces a woman’s desire for sex, therefore reducing the chance of sex outside marriage. The ability of unmutilated women to be faithful through their own choice is doubted. In many FGM- practising societies, it is extremely difficult, if not impossible, for a woman to marry if she has not undergone mutilation. In the case of infibulations, a woman is ‘sewn up’ and ‘opened’ only for her husband. Societies that practise infibulations are strongly patriarchal. Preventing women from indulging in ‘illegitimate’ sex and protecting them from unwilling sexual relations are vital because the honour of the whole family is seen to be dependent on it. Infibulation does not, however, provide a guarantee against ‘illegitimate’ sex, as a woman can be ‘opened’ and ‘closed’ again. In some cultures, enhancement of the man’s sexual pleasure is a reason cited for mutilation. Anecdotal accounts, however, suggest that men prefer unmutilated women as sexual partners. Cleanliness and hygiene feature consistently as justifications for FGM. Popular terms for mutilation are synonymous with purification (tahara in Egypt, tahur in Sudan), or cleansing (sili-ji among the Bambarra, an ethnic group in Mali). In some FGM-practising societies, unmutilated women are regarded as unclean and are not allowed to handle food and water. Connected with this is the perception in FGM-practising communities that women’s unmutilated genitals are ugly and bulky. In some cultures, there is a belief that a woman’s genitals can grow and become unwieldy, hanging down between her legs, unless the clitoris is excised. Some groups believe that a woman’s clitoris is dangerous and that if it touches a man’s penis he will die. Others believe that if the baby’s head touches the clitoris during childbirth, the baby will die. Ideas about the health benefits of FGM are not unique to Africa. In 19th century England, there were debates as to whether clitoridectomy could cure women of ‘illnesses’ such as hysteria and ‘excessive’ masturbation. For these reasons, clitoridectomy continued to be practised well into this century in the United States. However, health benefits are not the most frequently cited reason for mutilation in societies where it is still practised; where they are, it is more likely to be because mutilation is part of an initiation where women are taught to be strong and uncomplaining about illness. Some societies where FGM is practised believe that it enhances fertility, the more extreme believing that an unmutilated woman cannot conceive. In some cultures it is believed that clitoridectomy makes childbirth safer. Women and Health Learning Package: Female Genital Mutilation 8 www.the-networktufh.org
Testimony from a victim of FGM
I was genitally mutilated at the age of ten. I was told by my late grandmother
that they were taking me down to the river to perform a certain ceremony, and
afterwards I would be given a lot of food to eat. As an innocent child, I was
led like a sheep to be slaughtered.
Once I entered the secret bush, I was taken to a very dark room and
undressed. I was blindfolded and stripped naked. I was then carried by two
strong women to the site for the operation. I was forced to lie flat on my back
by four strong women, two holding tight to each leg. Another woman sat on
my chest to prevent my upper body from moving. A piece of cloth was forced
in my mouth to stop me screaming. I was then shaved.
When the operation began, I put up a big fight. The pain was terrible and
unbearable. During this fight, I was badly cut and lost blood. All those who
took part in the operation were half-drunk with alcohol. Others were dancing
and singing, and worst of all, had stripped naked.
I was genitally mutilated with a blunt penknife.
After the operation, no one was allowed to aid me to walk. The stuff they put
on my wound stank and was painful. These were terrible times for me. Each
time I wanted to urinate, I was forced to stand upright. The urine would
spread over the wound and would cause fresh pain all over again. Sometimes I
had to force myself not to urinate for fear of the terrible pain. I was not given
any anaesthetic in the operation to reduce my pain, nor any antibiotics to fight
against infection. Afterwards, I haemorrhaged and became anaemic. This was
attributed to witchcraft. I suffered for a long time from acute vaginal
infections.
(Source: Amnesty International)
A call for action
All health professionals must act to prevent this harmful and violent practice which is
barbaric and against women’s human rights.
Health professionals can intervene by disseminating information about FGM and its effects
on women’s health. Developing joint effort research and action between all the countries
affected could lead to a better understanding of the problem. Educational programs could
include intensive health education and community mobilization, and work with general
public to discourage people from taking their daughters for circumcision. Working with the
traditional practitioners and getting them to act as agents to enlighten parents and discourage
them from this practice is another option. Working with the younger generation to avoid
female circumcision can be achieved through campaigns in schools and workplaces in order
to achieve a positive societal change of attitudes about FGM.
Women and Health Learning Package: Female Genital Mutilation 9
www.the-networktufh.orgFemale genital mutilation produces morbidity in all countries affected and may also contribute to their mortality rates. At the same time, the practice encodes central values about gender, male-female relationships, maturity, and community. The resolution of this tension requires a deeper, more comprehensive, and better-quantified understanding than we now have in order to develop innovative and constructive solutions to address the negative effects of these practices on women’s health. Women and Health Learning Package: Female Genital Mutilation 10 www.the-networktufh.org
REFERENCES Amnesty International (1998). Female Genital Mutilation: A human rights information pack. Available at http://www.amnesty.org/ailib/intcam/femgen/fgm1.htm Aziz FA (1980). Gynaecological and obstetric complication of female circumcision. International Journal of Gynaecology and Obstetrics. Baasher T (1979). Psychological aspects of female circumcision. In: WHO/EMRO 1979: 71- 105. Daniel WF (1947). The Circumcision of females in West Africa. Medical Gazette of London. Daw RC (1970). Female circumcision and infibulation complicating delivery. The Practitioner. Diri MA, Mark GL. (1992). The risk of medical complications of female circumcision. East African Medical Journal. Vol.69. Hosken F (1979). Genital and sexual mutilation of females. Lexington, WIN-News. Priedie E, Lorenzen A, Gruickshank., Hovel, J.S., McDonald, D. K., Badri, Ali., Halim, M., AbuShma,A., and Eltigani, Almahi. (1945). Female circumcision in the Anglo-Egyptian Sudan. McCorcodale. Printing press. S.G. 1185.C.S.5000. 6/51. Reymond L, Mohamud A, Ali N. Female Genital Mutilation – The Facts. PATH. Available at: http://www.path.org/files/FGM-The-Facts.htm Rushwan , H. (1983). Female circumcision in the Sudan, prevalence, complications, attitude and changes. University of Khartoum. Raqiya, H, .(1982). Sisters in affliction: circumcision and infibulation of women in Africa. Zed Books Ltd., London and New Jersey. Shandel, A., and Abul Futuh, A. (1967). Circumcision and infibulation of females. Sudan Medical Journal Vol. 69. Thomas-Koso, Olayinka. (1987). The circumcision of women: A strategy for eradication. Zed Books, London, New Jersey. Verzein, J. A. (1975). Sequale of female circumcision. Tropical Medicine, Vol. 5. Worsely, A. (1983). Infibulation and female circumcision. A study of a life known custom. Journal of Obstetric and Gynaecology of the British Empire. Vol. 45. World Health Organization. Female Genital Mutilation Report of a WHO Technical Working Group, Geneva, 17-19 July 1995. Available at http://www.who.int/docstore/frh- whd/FGM/Technical_Working_Group/English/Technical_Working_Group.htm Women and Health Learning Package: Female Genital Mutilation 11 www.the-networktufh.org
Case Study: Fatima
Fatima was seven years old, the third child and only daughter in a family from Eldamar, a
small town in northern Sudan. When she was five years old, her mother sent her to live with
her grandmother in a nearby village because she couldn’t manage to take care of all three
children on her own. In the village, Fatima stayed at home helping her grandmother in daily
activities, and did not receive any formal education.
During a big feast and celebration, Fatima was persuaded by her grandmother to be
circumcised by the village midwife. Her grandmother bought her new dresses and golden
earrings. Fatima was very happy, but didn’t know what would happen to her. The ceremony
was held early in the morning.
Unfortunately, Fatima developed complications following the circumcision procedure. Her
grandmother brought her to the village health centre with severe bleeding and pain.
The medical assistant at the village health centre examined Fatima and found that she had
been severely genitally mutilated, which had caused serious damage and bleeding. The
medical assistant did his best to stop the bleeding.
After five days, Fatima was transferred to Eldamar hospital because there was still slight
bleeding and no improvement in her general condition, and she was admitted for treatment
and close observation.
On the sixth day Fatima developed urine retention, which was relieved by a folly catheter.
On the seventh day Fatima started to develop a high-grade fever, due to a very bad wound
infection. Fatima became pale and lost consciousness due to continuous blood loss. The
doctor recommended a blood transfusion and high doses of antibiotics.
On the eighth day her condition deteriorated, and Fatima died.
When her grandmother was asked about the incident, she said that if Fatima had not been
circumcised, it would have brought shame to the family and that no one would have married
her.
Questions for students
1. What are the various factors that influence the practice of FGM?
2. What measures can be taken to ensure that girls will not be forced to undergo FGM?
3. What are the role and responsibilities of health authorities?
4. What kinds of complications can occur as a result of FGM?
Women and Health Learning Package: Female Genital Mutilation Case Study: Fatima
www.the-networktufh.orgCase Study: Fatima – Tutor’s Notes
Dear Tutor:
As a tutor on this topic, we suggest that you provide ample opportunities for students to be
self-directing and active in their own quest for knowledge and reflection by working through
the preceding case study in a discussion session. This means that you will need to be patient
and refrain as much as possible from providing all the necessary answers to the students. It
also means that you might need to encourage the more reserved and quieter members of the
group to share their views and queries on the case study presented.
Fatima’s story was specifically selected to introduce the problem of FGM and scope of
women’s health in the context of socio-cultural, geopolitical, educational, and human
relations perspectives. This case study illustrates how young girls are suffering and how they
are treated in communities where FGM is a cultural norm. We see how FGM affects
women’s physical, social, emotional and mental well-being, which are the components of the
WHO definition of health.
The objective of the discussion session is not to concentrate on a solution or a diagnosis of
the problem and its detailed clinical management. Rather, the focus is on understanding and
reflecting on the underlying issues and mechanisms that are involved, and their relationship
to the severity of symptoms and signs presented by this young child.
The tutor is thus encouraged to invite students to explore the wider meaning of women’s
health outside the scope of diagnosis and management of disease states specific to women.
As such, an open-ended, less structured approach to the discussion is encouraged.
Questions related to the case studies are included as a guideline and not as a compulsory or
strict protocol for the group discussion. Ideally, students themselves in the course of working
through the case study in the discussion should raise these questions. You are thus requested
to hold on to the question sheets and distribute them (if you wish) at the end of the discussion
session.
Suggested points and questions for discussion
(Question and topics should come from the students)
1. What are the various factors that influence the practice of FGM?
• Societal norms
• Culture
• Religion
• Education
• Ceremonial practices surrounding FGM and their effect on young girls
• Low income/educational levels of health personnel (midwives)
• The dominant role of the grandmother in the family
• The role of the midwife or other practitioner in performing FGM
2. What measures can be taken to ensure that girls will not be forced to undergo
FGM?
Women and Health Learning Package: Female Genital Mutilation Case Study: Fatima – Tutor’s Notes
www.the-networktufh.org• Access to information and education
• Communication and dialogue about FGM among families and communities
• Political commitment to change
• Increase in awareness among policymakers, religious leaders, healthcare providers
and community members about FGM and its effects
• Development of legislation against the practice of FGM
• Inclusion of the topic of FGM in the curriculum of the regular education system
• Inclusion of men in any campaign against FGM
3. What are the role and responsibilities of health authorities?
• To include the topic of FGM in the curriculum of health and medical personnel
• To train health care providers in the management of complications resulting from
FGM
• To raise the awareness of midwives’ and other traditional FGM practitioners about the
risks associated with the practice
• To create incentives so that midwives can increase their incomes, and will not have to
practice FGM as a source of additional income
4. What kinds of complications can occur as a result of FGM?
• Physical
• Mental
• Social
Women and Health Learning Package: Female Genital Mutilation Case Study: Fatima – Tutor’s Notes
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