Female genital mutilation is a human rights issue of concern to all women and men.

Abstract

Societies often have deeply rooted and valued traditions, customs, and beliefs that are particular to them. While some traditions are beneficial or harmless, there are those that do great harm and carry significant risks to health. Female genital mutilation (FGM) falls into the latter category. As a midwife, nurse, woman and human being, this practice strikes a deep cord within me as being a cruel and dreadful burden for girls and women to bear. FGM is defined by WHO/UNICEF/UNFPA as ‘all procedures that involve partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural and other nontherapeutic reasons’ (World Health Organization 1997). The World Health Organization (WHO) estimates that 100–140 million girls and women living today have undergone some form of female genital mutilation. An additional 2 million girls are believed to be at risk from the practice each year. While most live in 28 African countries** Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Ivory Coast, Djibouti, Egypt, Eritrea, Ethiopia, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Republic of Congo, Senegal, Sierra Leone, Somalia, Sudan, Togo, Uganda, Tanzania. , FGM is increasingly emerging in a few Middle East and Asian countries, in Europe, Canada, Australia, New Zealand and the United States of America. The death rate is not easy to measure. In Sudan, a country with a prevalence rate of 89% (WHO 2001a), it is estimated that in some areas one-third of the girls undergoing FGM will die (Women's Policy Inc. 1996). This means that thousands of girls and women die prematurely, and if they survive the initial trauma, are subject to a high morbidity rate. The untold physical and mental suffering of girls and women throughout life as a result of FGM places enormous stress on daily lives, and strains health services that are often unable to cope with this burden of disease. My knowledge and understanding of the impact of FGM increased immeasurably when I started to attend meetings of the Geneva NGO Group on Traditional Practices Affecting the Health of Women and Children (IAC) on behalf of the International Council of Nurses (ICN). Above all I came to understand that FGM is a human rights issue that concerns all women and men who believe that equality, dignity, fairness and humanity should guide our relationships with each other. However, a number of factors have precluded FGM from being seen as a violation of human rights. Examples of reasons explaining this situation are that parents and family members sincerely believe FGM is beneficial for the girl later in life, and the perception that outside interference from those wishing to end the practice is a form of cultural imperialism. ICN strengthened its position on FGM in 1995 (International Council of Nurses 1995). It charged nursing organizations with taking an active role in educating and informing nurses, other health professionals, and the public. It stressed the importance of nurses collaborating with other interested groups to develop policies, strategies, and, where necessary, legislation that will lead to the elimination of this practice. (The full text of the ICN position statement on FGM is available at http:www.icn.ch.) As awareness of the adverse health consequences increased, health professionals have become involved in a medicalization of FGM, that is, performing the procedure in clinical conditions to reduce the health risks. ICN believes that a basic ethic of health care is that health services personnel cannot condone or take part in any activity that leads to body mutilation. Therefore ICN takes a clear and firm stand against all moves to medicalize FGM. It has not been easy to put FGM on the international agenda. This is despite the fact that the most comprehensive international instrument on women's rights, the 1979 Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) (UN 1979), which 169 countries had ratified by May 2002, included provisions (Art. 2f, Art. 5a) that can be interpreted as requiring states to act against FGM. Nearly two decades ago, African women took matters into their own hands and formed the IAC. By campaigning to make the international community take notice of the extent and seriousness of the problem, they laid the groundwork for the important 1994 World Health Assembly resolution calling on member states to establish national policies and practices to abolish FGM, and other harmful traditional practices (World Health Assembly 1994). In a further move, the 1994 Cairo International Conference on Population and Development (ICPD) (UN 1994) and the 1995 Fourth World Women's Conference (UN 1995) put FGM firmly into the category of violence against women. As awareness of the adverse health consequences increased, health professionals have become involved in a medicalization of FGM, that is, performing the procedure in clinical conditions to reduce the health risks. ICN believes that a basic ethic of health care is that health services personnel cannot condone or take part in any activity that leads to body mutilation. Therefore ICN takes a clear and firm stand against all moves to medicalize FGM. WHO documents on female genital mutilation (FGM) are available on the web site http://www.who.intfrh-whd. The publications also can be ordered directly from WHO by contacting: Gender and Women's Health Department WHO Avenue Appia 20 CH-1211 Geneva Fax: + 41 22 791 31 11; e-mail: wmh@who.int Much remains to be done. A WHO review of the programmes and strategies being undertaken to eliminate FGM pointed out that most of the organizations implementing anti-FGM activities are small and rely heavily on volunteers. Their activities do not yet reach most of the communities that still practise FGM. Governments have not, for the most part, moved beyond policy support to fully incorporate anti-FGM activities into their work (WHO 1999). This was brought home to me during discussions at a WHO Technical Working Group meeting on FGM in 1995. The members of that group were unanimous in their agreement that doctors, nurses and midwives are poorly prepared to carry out information and advocacy work for FGM elimination, and inadequately educated to care for FGM victims. We learned that poor documentation concealed the true extent of the practice, hindered health planning necessary to tackle the problem, and affected research efforts adversely. The technical group also noted how rarely, if at all, the consequences of FGM – physical, psychological and sexual – are dealt with in detail in the curricula of nurses, midwives and other health professionals (WHO 2001b). Additionally, it was acknowledged that there was little policy guidance on how FGM should be documented, and how to deal with controversial issues such as re-stitching up an opened up vulva (re-infibulation) (WHO 2001c). In 2001, WHO published educational materials and policy guidelines for educating nurses and midwives about FGM, and teaching them how to skilfully and sensitively care for girls and women, who too often suffer in silence the consequence of FGM. The WHO materials are a welcome and valuable addition to available tools. Nurses, as citizens, as health care providers and through their professional organizations need to increase pressure for elimination of the practice. We need to understand and be nonjudgemental about the significance of FGM in a society. We need to be knowledgeable about strategies that have been successful in combating the practice. Finally we must act with compassion, sensitivity and professional competence when providing care to the girls, women and families that are affected. Fadwa A. Affara retired in 2001 from her position as ICN Nurse Consultant for Nursing and Health Policy. Educated as a nurse and midwife, she has practised in both fields in the UK and abroad. After obtaining a MSc in Nursing with a speciality in education, she spent 12 years in nursing education, initially in Scotland and then in Bahrain where she oversaw the reform of nursing education. She joined the International Council of Nurses in 1987. Her responsibilities at ICN included women's health, child health, education, regulation, and the International Classification for Nursing Practice®. We welcome responses from readers. Please send letters or comments to: International Nursing Review, 3 place Jean-Marteau, CH 1201-Geneva, Switzerland Or e-mail your comments to: J. Harrington at harrington@icn.ch