Abstract

“I was just seven years old when I was cut,” says Leyla Hussein, a British woman of Somali origin. “The first thing I heard was my sister screaming. Then it was my turn. Four women held me down while they cut my clitoris. I felt every single cut. The pain was so intense – I blacked out.”

Hussein's experience of female genital mutilation (FGM) is fairly typical. The ancient rite of passage in many African and some Middle Eastern countries in which part or all of the genitals are cut off with razors or knives – often without anaesthetic – is supposed to make girls “clean” and “pure”, and ready for marriage.

The grim reality is that an estimated 125 million women and girls living today have undergone some form of FGM – many of them suffer severe emotional and physical consequences.

FGM is classified into four forms ranging from partial or total removal of the clitoris, the outer or inner vaginal lips to narrowing the vaginal opening by partially sealing it up.

In countries such as Djibouti, Egypt and Somalia more than 90% of girls undergo some form of FGM, some of them before they are old enough to walk.

The fight to end FGM is now global, with international agencies such as the United Nations Children's Fund (UNICEF) and the World Health Organization (WHO) at the helm, and has strong support from governments, such as that of the United Kingdom and nongovernmental organizations (NGOs). But for women like Hussein, now a London-based psychotherapist and anti-FGM campaigner, progress has been too slow.

A few countries have seen rates of FGM fall. In Kenya, these rates in women aged 15 to 49 years fell from 38% in 1998 to 26% in 2008; in the Central African Republic, rates fell from 43% in 1994 to 24% in 2010.

Yet most other African countries have seen rates stay stable or fall only marginally. Unless decisive action is taken to stop the practice, the United Nations Population Fund (UNFPA) projects that 86 million girls between 15 and 19 years will be subjected to FGM by 2030.

Since FGM has no health benefits and often leaves women with lifelong physical and emotional trauma, there is a human rights justification to end the practice, says Dr Joar Svanemyr, from the Department of Reproductive Health and Research at WHO, but he adds, “we have solid research evidence to show that FGM has devastating health effects.” These include painful menstrual periods and intercourse, urinary problems, and birth complications.

According to Dr Nafissatou Diop, FGM expert at UNFPA, FGM leaves a damning legacy, as “deaths among babies during and immediately after birth are higher for those born to mothers who have been cut.”

International pressure to end FGM has been mounting since 1997, when the WHO, UNICEF and UNFPA issued a joint statement calling on governments to ban the practice. This commitment was renewed in 2008 and, in 2012, the UN General Assembly passed a resolution to step up efforts towards the elimination of FGM.

“Since 2008, nearly 10 000 communities in 15 countries, representing about 8 million people, have renounced the practice,” says Diop. “While public declarations do not guarantee changes in actual behaviour, they have important symbolic value.”

A report on FGM released in July last year by UNICEF, entitled Female genital mutilation/cutting: a statistical overview and exploration of the dynamics of change, provides critical insight into the underlying cultural beliefs. It presents data showing that in many countries where FGM is practised most men and women think the practice should end. So what explains its continuity?

According to United Kingdom-based campaigner Hussein, who has talked extensively to men and women from communities where the practice is maintained, some women say they agree to the practice to ensure they are “marriageable,” while men think it is the women who want it.

UNICEF data support the impressions that women greatly underestimate the proportion of men who want FGM to end, and that high proportions of men and women have no idea what the other sex thinks about FGM.

The shroud of secrecy surrounding the practice results in ignorance about it, according to Hussein. “Most Somalis assume only Somalis do it, and Muslims were stunned to find out that Christians do it too,” says Hussein, adding that many researchers find that most women who have undergone the practice have no idea that their severe health problems – such as taking 15 minutes just to pass urine – are a consequence of FGM.

The importance of talking about FGM with honesty is also why Hussein objects to those who refer to the practice as “circumcision”, because it downplays the brutality of the procedure. “Telling me I've been cut when I've actually been mutilated is so offensive.”

Another major challenge in ending FGM is that health-care professionals are often complicit, performing the procedure themselves. This “wrongly legitimizes the practice and creates the inaccurate impression that it is beneficial for girls' and women's health, violating the fundamental ethical code that requires that physicians, nurses and midwives do no harm to any patient,” says Diop.

UNFPA and UNICEF are ramping up their efforts now to end the practice. Last October, they held a conference in Rome, Italy, to review the results of four years of FGM abandonment programmes in 17 countries and discuss their strategy for the next five years.

According to Diop, the key findings of the conference were that human rights-based education programmes should be continued, legislation against FGM should be enforced and funding both locally and nationally for initiatives to end FGM should be increased.

According to Diop and others working to end FGM, cooperation between countries will be crucial in ending the practice. In countries such as the United Kingdom and the United States of America with large African diasporas there is extensive anecdotal evidence that many girls are taken to their countries of origin or other places, such as Dubai, to have FGM, says Hussein. Better data on rates of FGM in these communities are urgently needed.

An estimated 66 000 women living in England and Wales in 2001 had undergone FGM, according to a study published in 2007 by the Foundation for Women's Health, Research and Development, a United Kingdom-based NGO. Despite a law passed in the United Kingdom in 1985 making the practice a criminal offence, there has not been one single prosecution.

Fighting FGM can lead to considerable aggression against campaigners. “I've had people punch me, spit on me, and recently someone told me I should ‘die a slow death',” says Hussein. “At times, I do feel like giving up.” What spurs her on is that the practice remains deeply hidden in diaspora communities, yet the USA, for instance, is home to the largest Somali community outside of Somalia. Despite this, FGM is poorly tracked in high-income countries. There are signs that this is changing, with the United Kingdom setting up a parliamentary group last October to discuss ways to end FGM.

Hussein is optimistic about the future but says that ending FGM will rely on honest conversation. “If we tiptoe around the issue, nothing happens. We need to educate women about their human rights. We need to call FGM what it is – the worst form of violence against girls and women – rather than let it hide under a cultural banner. It is child abuse, and we need it named as such because language is the most powerful way to fight it.”

According to Molly Melching, executive director of Senegal-based NGO Tostan, which collaborates with UNICEF and UNFPA and works with communities in Africa to end FGM, communities are the key. When communities “learn that a traditional practice carries risks they didn't know, and violates basic human rights in ways they had not understood, they start questioning the practice.”

Tostan uses “traditional African ways of mediation and communication – group discussions where everyone has the chance to express themselves.” The approach may be working: a 2008 UNICEF evaluation of Senegalese villages, where Tostan had been working since 1998, showed that 30% of girls had been cut compared with 69% in similar villages nearby where Tostan had not worked.

David Adam at the United Kingdom-based Orchid Project, which works with Tostan on grassroots projects, adds that public declarations for ending FGM are vital. “By spreading the message of abandonment along their social networks, neighbouring communities are introduced to the idea of abandonment, often reducing or even removing resistance to the idea.”

The future research challenges are implementational, says Dr Marlene Temmerman, director of the Department of Reproductive Health and Research at WHO. They include understanding how anti-FGM policies can be put in place and how to influence decision-makers. “The medical consequences of FGM need to be a key component of medical curricula, especially in Africa,” adds Temmerman, so that health professionals can diagnose and manage FGM-related complications.

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