Female Genital Cutting in the Nigeria Context

IN A NUTSHELL
Author's note
…In this paper, details of female genital cutting-FGC (or female genital mutilation-FGM as interchangeable terms) will be discussed within the context of Nigeria…

…Even though cultural norms and values are integral elements in shaping views and behavioral patterns of the community, FGC is one of the harmful cultural beliefs and practices that have no scientific proven medical basis and therefore must be abolished…

…The WHO has advised that neither FGM must be institutionalized nor should any form of FGM be performed by any health professional in any setting, including hospitals or in the home setting…

By Dr. Hadiza Magaji Mahmoud, MBBS

Masters in Reproductive Health, MSc Public Health (LSHTM), AMRSPH

By the same Author on PEAH: HERE

Female Genital Cutting in the Nigeria Context

 

‘’INTERVENTIONS TO MODIFY SEXUAL PLEASURE AND PERFORMANCE ARE NEVER SOLELY ABOUT ANATOMY AND PHYSIOLOGY BUT ARE HEAVILY INFLUENCED BY SOCIAL, CULTURAL, AND POLITICAL CONTEXT AND NORMS.”

 

The statement above highlights the idea that sexual experiences are shaped by a variety of factors beyond just biological processes. These factors include social norms, cultural values, political ideologies, and personal beliefs, all of which can impact sexual behaviors, attitudes, and expectations.

In the settings of Female Genital Cutting (FGC), modification of the normal external female anatomy does not only change the anatomy or physiologic function but also have implications on sexuality and general wellbeing. In addition, factors like social, cultural, and political context and norm do contributes in larger proportions towards causing harm to one’s sexuality.

In this paper, details of female genital cutting will be discussed within the context of Nigeria giving into account how such practice influenced by social norms, cultural values, political ideologies and personal beliefs will have impact on sexuality.

Female genital mutilation is also known as female circumcision or female genital cutting. The terms will be used interchangeable in this paper.

Female genital mutilation (FGM) is defined by the World Health Organization (WHO) as all procedures which involve partial or total removal of the external female genitalia and/or injury to the female genital organs, whether for cultural or any other non-therapeutic reasons.1

An estimated 140 million women have undergone Female genital cutting.2 In Africa alone, an estimated 101 million girls above the age of 10 years have undergone the procedure with an estimated 3 million being at risk of undergoing FGC each year.2

Though FGC is practiced in more than 28 countries in Africa and a few scattered communities worldwide, its burden is seen in Nigeria, Egypt, Mali, Eritrea, Sudan, Central African Republic, and northern part of Ghana where it has been an old traditional and cultural practice of various ethnic groups.3,4

Nigeria has the highest absolute number of cases of FGC in the world, accounting for about one-quarter of the estimated 115–130 million circumcised women worldwide.3 The national prevalence rate of FGC is 41% among adult women. Prevalence rates progressively decline in the young age groups and 37% of circumcised women do not want FGC to continue.3 FGC has the highest prevalence in the south south (77%) (among adult women), followed by the south east (68%) and south west (65%), but practiced on a smaller scale in the north, paradoxically tending to a more extreme form.3,5

The practice is widespread among different tribes and religions. FGC practice was deeply entrenched in the culture in all geopolitical zones of the country.6

In Nigeria, the practice is performed on neonates, infants, pubertal, antepartum, or post-partum women.7,8 In most part of the country, it is carried out at a very young age (minors) and there is no possibility of the individual’s consent.9

FGC practiced in Nigeria is classified into four types10 as follows: Type I or Clitoridectomy (the least severe form of the practice): It involves the removal of the prepuce or the hood of the clitoris and all or part of the clitoris. In Nigeria, this usually involves excision of only a part of the clitoris. Type II or “sunna” is a more severe practice that involves the removal of the clitoris along with partial or total excision of the labia minora. Type I and Type II are more widespread in Southern Nigeria but less harmful compared to Type III which is commoner in Northern Nigeria. Type III (infibulation) is the most severe form of FGC. It involves the removal of the clitoris, the labia minora and adjacent medial part of the labia majora and the stitching of the vaginal orifice, leaving an opening of the size of a pin head to allow for menstrual flow or urine. Type IV or other unclassified types recognized by include introcision and gishiri cuts, pricking, piercing, or incision of the clitoris and/or labia, scraping and/or cutting of the vagina (angurya cuts), stretching the clitoris and/or labia, cauterization, the introduction of corrosive substances and herbs in the vagina, and other forms.7

FGC procedure is usually performed by traditional barbers, traditional healers, traditional birth attendants, and to some extents trained midwives and community health workers.

Various reasons have been given for performing FGC in Nigeria. In some communities, the procedure is observed as a religious rite, even though the role of religion in propagating the practice is extremely controversial. Interestingly, this practice is carried out among Muslims, Christians and others in the communities where it is seen. There is no clear evidence in the Bible or Qur’an supporting female circumcision.11

Female circumcision is sometimes performed as an initiation rite into womanhood or into the tribe. An important reason forwarded by others for this practice is to safeguard the virginity of girls until marriage, or as a means of attenuating sexual desires of the girls thus rendering them less vulnerable to sexual temptation .12

Among the Yorubas of Ekiti and Atakumasi in Osun State, clitoridectomy is performed so that the head of the new born does not come in contact with the clitoris during delivery. If it does, these people believe it will result in the death of the newborn infant.13

In case of hypertrophy of the labia minora, circumcision is done for aesthetic reasons. Sometimes it is done for hygienic reasons.11

FGC is recognized worldwide as a fundamental violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes and constitutes an extreme form of discrimination against women. It involves violation of rights of the children and violation of a person’s right to health, security, and physical integrity, the right to be free from torture and cruel, inhuman, or degrading treatment, and the right to life when the procedure results in death. Furthermore, girls usually undergo the practice without their informed consent, depriving them of the opportunity to make independent decision about their bodies.7 Another implication of FGC at early childhood age is that the female themselves grow into adulthood without the awareness of having had genital mutilation.

The complications of female genital cutting depend on the type and extent of the procedure. The most severe form, infibulation, which is usually carried out by untrained personnel in rural settings, carry the greatest health hazard been increased morbidity, psychological problems, and even death.11

FGC has been associated with various sexual and reproductive health challenges in literatures, including sexual dysfunction, painful intercourse, infertility, clitoral cyst, reduced sexual desire and satisfaction, and recurrent urinary tract infection 14,15

Difficulty of sexual intercourse and sexual dysfunction with resultant sexual dissatisfaction, especially in the female, could result in marital disharmony, reactive depression and in some cases psychosis.16

However, recent work on the sexual experiences of women with FGC is relatively lacking in FGC burden countries including Nigeria. The latest study on this issue utilized 2008 NDHS data to investigate the relationship between FGC and sexual behavior assessed using age at sexual initiation and number of lifetime partner.17

The results of a study conducted in Edo State, Nigeria indicate that genital cutting does not reduce the level of sexual activity in women. By contrast, the study suggest that genital cutting may predispose women to adverse sexuality outcomes including early pregnancy and reproductive tract infections.18

The study which utilizes the NDHS data, talks about female genital cutting and sexual behavior by marital status among a nationally representative sample of Nigerian women, it shows there is no evidence to support the claim that FGC prevents premarital sex and ensures marital fidelity in Nigeria 19  and is in consonance with another study that found no relationship between female genital circumcision and age at first intercourse in Nigeria and Kenya 20, and disproves the assertion that circumcised women were more likely to initiate first sexual experience compared to uncircumcised women.21 This study also revealed that ever married women who were mutilated were at lower risk of having multiple sexual partners in contrast to a study in Sierra Leone that showed an increased risk of multiple sexual partners among circumcised women.22

The study disproves one of the cultural beliefs deeply held to which also forms a basis for the practice of FGC, which is supposedly aimed at reducing promiscuity and ensuring acceptable sexual behavior including virginity and fidelity 23,24. Therefore, there is need to understand the underlying complexities of this cultural belief in order to design successful, culturally acceptable, and correctly targeted FGM eradication campaigns 24, 25. However, there are some potential limitations to this particular study, causal relationship was not established as national data was used for interpretation and FGC was self-reported by participants. Therefore, some questions assessing sexual behavior characteristics may be under reported (example, under reporting of age at first sexual initiation or virginity status due to societal and cultural expectations). To address such limitations, studies that test true causal relationship should be used and good methodological approach towards data collection should be encouraged. Generally, emphasis should be made to encourage more research on FGC especially in the Northern Nigeria where only few studies are available and such practices are still carried out.

Many initiatives, approaches and efforts that have been initiated to eradicate the practice of FGM including increasing legislation 15, 24 and messaging that inform on the adverse health effects are without much success 26,27,28. Exposure of negative health consequences or criminalization of the practice often time results in the medicalization of FGC and introduction of various methods to continue the practice secretly 29. Nigeria ratified the Child Rights Charter in 2001 30 and outlawed FGC in 2015 by enacting the Violence Against Persons (Prohibition) Act 31. Many state governments have also domesticated the Child Rights Act and criminalized FGC in their respective states, but with little to show for it, as the trend for FGC continues with minimal decline.32

In Nigeria, FGM is being tackled by WHO, United Nations International Children Emergency Fund (UNICEF), Federation of International Obstetrics and Gynecology (FIGO), African Union, the Economic Commission for Africa (ECA), and many women organizations. Intensification of education of the general public at all levels has been done with emphasis on the dangers and undesirability of FGM.7

Even though cultural norms and values are integral elements in shaping views and behavioral patterns of the community, FGC is one of the harmful cultural beliefs and practices that have no scientific proven medical basis and therefore must be abolished.

A multidisciplinary approach is needed to tackle this deep rooted legendary practice of FGM. There is a need for legislation in Nigeria with health education and female emancipation in the society. The process of social change in the community with a collective, coordinated agreement to abandon the practice “community-led action” is therefore essential.34 With improvement in education and social status of women and increased awareness of complications of FGM, most women who underwent FGM disapprove of the practice and only very few are prepared to subject their daughters to such harmful procedures.4 The more educated, more informed, and more active socially and economically a woman is, the more she is able to appreciate and understand the hazards of harmful practices like FGM and sees it as unnecessary procedure and refuses to accept such harmful practice and refuses to subject her daughter to such an operation.7

Medicalization of FGC involving trained health workers might reduce harm especially in communities resistant to change. Though, the WHO is strongly against this medicalization and has advised that neither FGM must be institutionalized nor should any form of FGM be performed by any health professional in any setting, including hospitals or in the home setting.33Stakeholders should support families and communities to strengthen their efforts toward abandoning the practice and to improve care for those who have undergone FGC. A culturally acceptable approach respecting individual’s values and beliefs regarding FGC should be encouraged to help improve sexual and overall wellbeing across population groups.

 

REFERENCES

  1. World Health Organization: Female Genital Mutilation: An overview. Geneva: World Health Organization; 1998.
  2. WHO. 2013. Female Genital Mutilation. World Health Organization. http://who.int/mediacentre/factsheets/fs241/en (accessed September 18, 2015).
  3. UNICEF. Children’s and Women’s right in Nigeria: A wake up call. Situation Assessment and Analysis. Harmful Traditional Practice (FGM) Abuja NPC and UNICEF Nigeria; 2001. p. 195-200.
  4. Odoi A T. Female genital mutilation: In Kwawukume EY, Emuveyan EE (eds) Comprehensive Gynecology in the Tropics. 1st ed. Accra: Graphic Packaging Ltd; 2005. p. 268-78.
  5. Adegoke P. Ibadan University Humanist Society. Female Genital Mutilation: An African Humanist view. November, 2005
  6. Kolawole, A. O. D., and K. Anke. 2010. A review of determinants of female genital mutilation in Nigeria. Journal of Medicine and Medical Sciences1 (11):510–15
  7. Okeke, T. C., U. S. B. Anyaehie, and C. C. K. Ezenyeaku. An overview of female genital mutilation in Nigeria. Annals of Medical and Health Sciences Research. 2012; 2 (1):70–73. doi: https://doi.org/10.4103%2F2141-9248.96942
  8. Okhiai, O. I., O. B. Donije, and E. C. Asika. Awareness of health risks of female genital mutilation among women of childbearing age in two rural communities of Nigeria. Asian Journal of Medical Sciences. 2011; 3 (6):223–27.
  9. Hathout HM. Some aspects of female circumcision. J Obstet Gynaecol Brit Emp 1963; 70:505-7.
  10. World Health Organization. Female genital mutilation. A joint WHO/UNICEF/UNFPA statement. Geneva: World Health Organization; 1997.
  11. Mandara. M.U. et al. Female genital mutilation in Nigeria. International Journal of Gynecology and Obstetrics 84 (2004) 291–298 doi: 10.1016/j.ijgo.2003.06.001
  12. WHO. Female genital mutilation: information kit. WHO/FRH/WHD/.26. 1996. p. 96.
  13. Oguntuyi A. History of Ekiti. Ibadan: Bisi Books, 1979. p. 28 –29.
  14. Alsibiani SA, Rouzi AA. Sexual function in women with female genital mutilation. 64th annual meeting of the American Society for Reproductive Medicine. San Francisco, California., Elsevier Inc 2008.
  15. Berg RC, Denison E, Fretheim A. Psychological, social and sexual consequences of female genital mutilation/cutting (FGM/CFGM/C): a systematic review of quantitative studies. Report from Norwegian Knowledge Centre for the Health Services. 2010:13.
  16. Mustafa AZ. Female circumcision and infibulation in the Sudan. J Obstet Gynaecol Br Cwlth 1966; 73:302 –306.
  17. World Bank’s total population and age/sex distributions of the United Nations Population Division’s World Population Prospects: 2019 https://data. world bank. org/ indicator/ SP. POP. 1564. TO. ZS.
  18. Okonofua. F.E. et al.  The association between female genital cutting and correlates of sexual and gynecological morbidity in Edo State, Nigeria. An International Journal of Obstetrics and Gynecology October 2002, Vol. 109, pp. 1089–1096
  19. Adelekan et al. Female genital mutilation and sexual behavior by marital status among a nationally representative sample of Nigerian women. Reproductive Health. (2022) 19:91 https://doi.org/10.1186/s12978-022-01379
  20. Mpofu S, Odimegwu C, De Wet N, Adedini S, Akinyemi J. The relation of female circumcision to sexual behavior in Kenya and Nigeria. Women Health. 2017;57(7):757–74. https:// doi. org/ 10. 1080/ 03630 242. 2016. 1206054 (Epub 2016 Jun 29 PMID: 27355616).
  21. Wagner N. Why female genital cutting persists, International Institute of Social Studies at Erasmus University Rotterdam, Kortenaerkade 2012. https:// www. Research gate. net/ profi le/ Natascha_ Wagne r2/ publi cation/ 22882 9687_ Why_ female_ genit al_ cutti ng_ persi sts/ links/ 00b49 5236cb68a3 90e00 0000.pdf.
  22. Ahinkorah B, Hagan J, Seidu A, Budu E, Armah-Ansah E, Adu C, Yaya SE, et al. Empirical linkages between female genital mutilation and multiple sexual partnership: evidence from the 2018 Mali and 2013 Sierra Leone Demographic and Health Surveys. J Biosoc Sci. 2018; 2021:1–16. https://doi. org/ 10. 1017/ S0021 93202 10001 09.
  23. Ojo TO, Ijadunola MO. Socio-demographic factors associated with female genital cutting among women of reproductive age in Nigeria. Eur Soc Contracep Reprod Health. 2017. https:// doi. org/ 10. 1080/ 13625 187. 2017.13280 48.
  24. Working with Women and Girls Who Have Experienced Female Genital Cutting http:// www. serc. mb. ca/ site/ default/ files/ resources/ WrkwithWomen% 26Gir ls2015. pdf. 2015.
  25. Ismail EA. Female genital mutilation survey In: Somaliland. Hargeisa, Somaliland: The Edna Adan Maternity and Teaching Hospital; 2009.
  26. Population Council. Using Operation Research to Strengthen Programs for Encouraging abandonment of Female Genital Cutting. Report of the Consultative Meeting on Methodological Issues for FGC Research Nairobi http:// www. popco uncil. org/ pdfs/ front iers/ nairo bi_ fgcmtg. pdf.
  27. Behrendt A. Listening to African voices female genital mutilation/cutting among immigrants in Hamburg: Knowledge, Attitudes and Practice. Hamburg: Plan; 2012.
  28. Yirga WS, Kassa NA, Gegremicheal MW, Aro AR. Female genital mutilation: prevalence, perceptions and effect on women’s health in Kersa district of Ethiopia. Int J Women’s Health. 2012; 4:45–54.
  29. Feldman-Jacobs C, Ryniak S, Wilcher R, Shears K, Ellsberg M. Fua I, et al. abandoning female genital mutilation/cutting: an in-depth look at promising practices. Population Reference Bureau; 2006.
  30. Yerima TF, Atidoga DF. Eradicating the practice of female circumcision/female genital mutilation in Nigeria within the context of human rights. J Law Policy Global. 2014; 28:129–140.
  31. Muthumbi J, Svanemyr J, Scolaro E, et al. Female genital mutilation: a literature review of the current status of legislation and policies in 27 African countries and Yemen. Afr J Reprod Health. 2015; 19:32–40.
  32. T. O. Ojo & M. Y. Ijadunola (2017) Sociodemographic factors associated with female genital cutting among women of reproductive age in Nigeria. The European Journal of Contraception & Reproductive Health Care. 22:4, 274-279, DOI:10.1080/13625187.2017.1328048
  33. WHO Elimination of FGM in Nigeria Plot 617/618 Diplomatic drive, Central District Abuja. Family Health Department, Federal Ministry of Health Phase II Federal Secretariat Abuja Dec 2007.
  34. UNICEF. Changing a harmful social convention: Female genital mutilation/cutting. Innocent Digest. Florence: UNICEF; 2005.