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 away 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 physical and psychological.
There are thousands of similar stories from women and girls residing in Ireland who have undergone female genital mutilation (FGM).
New figures 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 practising communities in Ireland, and for more awareness of FGM among healthcare personnel.
FGM involves removal of either a part or all of the female external genital organ for cultural, traditional or any other non-medical reasons. This is a 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 on girls 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.
The origins 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 sex.
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.
This cruel practice persists today – even in African countries where recent legislation has made it illegal.
AkiDwA, the African and Migrant Women’s Network in Ireland, hopes to mark its 10th 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 in communities that widely practise FGM.
The Department of Health has for some time been planning to introduce new legislation specifically banning FGM.
The new Bill, it is understood, would 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 defence 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.
The previous Health Minister, Mary Harney had said she was committed to publishing the new FGM legislation. But with the imminent change in Govemnment, there is some uncertainty about the legislation.
“This legislation is very important to our work,” says Alwiye Xuseyn, a migrant women’s health officer at AkiDwA.
"It will support our work with healthcare professionals and the practising community to protect children and women at risk."
“There are a lot of women from practising communities living in Ireland and we need to educate them and their communities 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, 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 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 at such a young age.
“We have to protect women and girls of practising 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 being carried out in Ireland but, unfortunately, this is not the case in the UK, as indicated in several recent media reports. One respected newspaper claimed that 500-2,000 British schoolgirls are genitally mutilated over the summer holidays. Some are taken abroad, others are ‘cut’ in the UK by women already living there or who are flown in and brought to ‘cutting parties’ for a few girls at a time in a cost-saving exercise.
Dr Comfort Momoh, an international expert on FGM, who established the African Well Woman’s Clinic at Guy’s and St Thomas’ Hospital in London, says she sees over 400 women and girls every year at her clinic with FGM-related problems such as distressing flashbacks, recurrent urinary infections and difficulties during pregnancy and childbirth.
“In summer we get really anxious,” she adds. “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. The new legislation must be introduced without further delay.”
AkiDwA sees the medical profession as having a key role in the battle agaisnt FGM, 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 specific and urgent healthcare 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 healthcare professionals.
This led to a successful collaboration between Dr Nugent, her RCSI students and AkiDwA, to compile the first-ever Irish handbook on FGM, entitled Female Genital Mutilation: Information for Healthcare Professionals Working in Ireland.
This ‘toolkit’ was launched in January 2009 and almost 2,000 copies of the handbook have been distributed in Ireland and internationally. AkiDwA has received funding for a second print run.
“FGM is not well known in Ireland," says Dr Nugent. In fact, about 75% of our students on the masters course in women's health 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 doctors had a patient in front of them, they could access it online and it would address the immediate issues and 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 practised; a breakdown 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 types of FGM.
To date, over 560 healthcare professionals have attended FGM training course organised by AkiDwA, including classes in the Dublin maternity hospitals.
“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."
“It’s also important that when you have girls from these practising communities who come home from their holidays and are having pelvic or genital pain, to ask if anything like this has happened to them.”
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 FGM are likely to experience more severe health complications, but health consequences for type I have also been widely reported.
When 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 to the baby, and death of the mother.
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 bodies in Ireland, the UK and abroad stipulate that the woman must not be reinfibulated.
AkiDwA plans to develop a network of counsellors and doctors who are trained to help women with FGM.
“Communities that practise FGM often believe they are doing the best for their daughters. There are often pressures from home within some practising 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."
(This article appears in the latest issue of the medical journal 'Scope', also published by Medmedia.)
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