Friday, November 30, 2007

The physical and psychological effects of female genital mutilation

Physical effects

The effects of genital mutilation can lead to death. At the time the mutilation is carried out, pain, shock, haemorrhage and damage to the organs surrounding the clitoris and labia can occur. Afterwards urine may be retained and serious infection develop. Use of the same instrument on several girls without sterilization can cause the spread of HIV.

More commonly, the chronic infections, intermittent bleeding, abscesses and small benign tumours of the nerve which can result from clitoridectomy and excision cause discomfort and extreme pain.

Infibulation can have even more serious long-term effects: chronic urinary tract infections, stones in the bladder and urethra, 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 damaged 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 do this, perineal tears or obstructed labour can occur. After giving birth, women are often reinfibulated to make them ''tight'' for their husbands. The constant cutting and restitching of a 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 carry it out, make collecting data about complications resulting from mutilation difficult. When problems do occur these 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 the 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 this has been useful in acquiring a 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 are frequent.

Effects on sexuality

Genital mutilation can make first 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 a women's enjoyment. However, one study 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 of them psychological, may mitigate some of the effects of removal of the clitoris and other sensitive parts of the genitals.

Psychological effects

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. 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 the behaviour described as ''calmer'' 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 is the feeling that she is acceptable to her society, having upheld the traditions of her culture and made herself eligible for marriage, often the only role available to her. It is possible that a woman who did not undergo genital mutilation could suffer psychological problems as a result of rejection by the 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.

Short-term consequences

Severe pain and bleeding are the most common immediate consequences of all forms of FGM. Since in most cases the procedure is carried out without anaesthesia, the resulting pain and trauma can produce a state of clinical shock. In some cases, bleeding can be protracted and result in long-term anaemia.

Infections are also common, particularly if the procedure is carried out in unhygienic conditions or with unsterilized instruments, and in severe cases can include potentially fatal septicaemia and tetanus. Urinary retention is also a frequent complication, especially when skin is stitched over the urethra.

Long-term consequences

Long-term adverse effects include abscesses, painful cysts and thick, raised scars called keloids, which can, in turn, cause problems during subsequent pregnancy and childbirth. Deinfibulation, for the purpose of reopening the vaginal orifice after it has been stitched or narrowed, and reinfibulation, to reduce the vaginal opening after deinfibulation, are sometimes performed at each birth, with potentially dire health consequences. Other long-term complications include infertility and haematocolpos (the accumulation of menstrual fluid in the vagina).

Up to now, attempts to determine scientifically the incidence, prevalence and risk of specific health consequences of FGM have been hampered by the lack of well designed large-scale studies on the subject, as well as the reluctance and/or inability of many women and girls who have undergone the procedure to provide accurate details about the circumstances of their experience and the medical consequences that might, or might not be, attributable to it. What is believed to be the first large-scale study to break through the silence and confusion enshrouding the subject was conducted by an HRP study group. Based on direct observation of more than 28 000 women in six African countries, the prospective study shows clearly that FGM is associated with an increased risk of obstetric complications, including caesarean section, postpartum haemorrhage, extended hospital stays, the need for infant resuscitation, stillbirth, early neonatal death and low birth weight. (3)

Physical consequences are only part of the damage that a girl or woman may suffer as a result of FGM. A wide range of psychological and psychosomatic disorders have been attributed to the practice, among them disordered eating and sleeping habits, changes in mood and symptoms of impaired cognition that include sleeplessness, recurring nightmares, loss of appetite, weight loss or excessive weight gain, as well as panic attacks, and difficulties in concentrating and learning. (4,5)

The extent of psychological damage produced by FGM is difficult to ascertain. As Sudanese physician and surgeon Nahid Toubia, who is also associate professor at Columbia University School of Public Health in New York, USA, notes, “the psychological effects are often subtle and are buried in layers of denial”.(6) She believes that there may be additional psychological implications for the immigrant women who live in western societies in which FGM is not traditionally practiced. These women have to deal with the conflicting attitudes of their traditional culture and of western culture towards FGM, sexuality and women’s rights. Evidence of the psychological effects of FGM is beginning to appear among immigrant communities in Europe, America and Australasia. (7)

One often neglected aspect of the medical and psychological problems ascribed to FGM is their impact on a girl’s education: absenteeism, poor concentration, low academic performance and loss of interest have been associated with FGM. (8)

(3) WHO study group on female genital mutilation and obstetric outcome. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet 2006; 367:1835–41 (doi:10.1016/S0140-6736(06)68805-3).
(4) UNICEF. Global consultation on indicators, November 11–13, 2004, Child protection indicators framework. Female genital mutilation and cutting. New York, NY: UNICEF; 2004.
(5) Behrendt A, Moritz S. Posttraumatic stress disorder and memory problems after female genital mutilation. Am J Psychiatry 2005;162:1000–02.
(6) Toubia N. Female circumcision as a public health issue. N Engl J Med 1994;331:712–16.
(7) Johnsdotter S, Essén, B. Sexual health among young Somali women in Sweden: living with conflicting culturally determined sexual ideologies. Paper presented at the conference Advancing Knowledge on Psychosexual Effects of FGM: assessing the evidence, Alexandria, Egypt, 10–12 October, 2004; archive/00018019/01/Alexandria2004.pdf; visited on 24 July 2006.
(8) Basic education and female genital mutilation: GTZ topics. eng_basic_education.pdf; visited on 24 July 2006.

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