Female genital mutilation: Why healthcare providers should not do the ‘cut’

The little infant cried endlessly as the nurse applied powder to her genital, and kept pressing it hard. Finally, she used a blade to remove part of it.

The baby’s mother had gone to a nurse to perform the procedure because she believed it was more hygienic and safer.

Twenty-five-year old Amina hails from the North-East of the country where female genital mutilation is practiced. She recalled a medical doctor telling some women and girls during a social gathering that since the type of female genital mutilation in their culture involves ‘just cutting a bit of the clitoris,’ that it was okay for them to do it but that they should meet a qualified health professional to do it for them.

She said this advice gave some women at the gathering confidence that it is okay to continue the practice to fulfill culture so long as it is done ‘properly’ by a health personnel.

As more voices and efforts rise against female genital mutilation, more people are now abandoning the services of traditional circumcisers for medical and other allied health professionals.

Some parents go to the hospital or meet healthcare providers in their homes to do it for their children.

Experts have said that that since female genital mutilation has no benefits for women and girls, there is no need to do it, whether in bits or full, and that healthcare providers should not be involved in the practice.

They said that female genital mutilation has short and long term negative effects even when done by health professionals, and that medicalization of female genital mutilation frustrates efforts to end the practice for good.

They experts added that healthcare providers who encourage or participate in female genital mutilation even in in hospital settings are contributing to the negative effects of the practice on women in Nigeria.

The experts also called for sanctions against erring medical personnel in the country.

According to the World Health Organisation (WHO), female genital mutilation (FGM) comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.

WHO strongly urges health professionals not to perform such procedures. “While the practice is mostly carried out by traditional circumcisers, in many settings, healthcare providers perform female genital mutilation due to the erroneous belief that the procedure is safer when medicalized.,” it said.

Female genital mutilation is classified into four major types, the first type called clitoridectomy involves the partial or total removal of the clitoris. The second type; referred to as excision, involves the partial or total removal of the clitoris and the labia minora (the inner folds of the vulva). The third type called infibulation involves the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora (the outer folds of skin of the vulva), sometimes through stitching, with or without removal of the clitoris, according to WHO. This allows only a small hole for urinating and menstrual bleeding. The woman or girl may later be deinfibulated, that is cutting open the sealed vaginal opening to allow intercourse and childbirth.

The last type includes all other harmful procedures to the female genitalia for non-medical purposes, such as pricking, stretching, piercing, incising, scraping and cauterizing or inserting herbs in the genital area. Some effects of female genital mutilation include, urinary problems, sexual problems, infertility, infections, severe pain, maternal death, psychological problems, and death.

The five states with the highest prevalence of female genital mutilation in the country are: Osun, Oyo, Ekiti, Imo and Ebonyi.

Explaining medicalization of female genital mutilation, Dr Imran Bello , a gyneacologist, said it does not only mean healthcare professional performing the procedure, but also providing access to equipment, facility and training for those who engage in the act. He said some medical personnel have empowered traditional birth attendants to engage in the practice.

Dr Bello said some medical personnel provide anesthesia, or pain relief for the traditional service providers of female genital mutilation or go to people’s home to carry out the procedure. According to him, some hospitals have also integrated the practice into other existing activities such as immunisation, childbirth, antenatal care, and post-natal care .

“Medicalisation of female genital mutilation is harmful. It is a form of human right violation and child abuse, and also a medical malpractice because it is against the law and oftentimes we don’t get consent before we do it, ”he said.

Professor Oladosu Ojengbede, the Executive Director of the Centre for Population and Reproductive Health, University of Ibadan said medicalization of female genital mutilation is a new trend in the country and was fast becoming worrisome.

Ojengbede who is a professor of Gynaecology and Obstetrics said female genital mutilation is a form of gender-based violence which violates the rights of women. He said medicalization of female genital mutilation encourages traditional practitioners to continue in the trade, believing they were being cheated out of their trade .

He added that culture of silence and lack of laws in some states slows sanctioning of erring medical personnel who perform female genital mutilation and those that support them.

He said: “It is a surgery performed without the consent of the person and prevalent in Asia and Africa. The long and short term consequences makes it important to end the practice. You can’t be telling the local or traditional people to stop the practice, and you a doctor or nurse then begins to engage in it. By medicalising it, you are rolling back the gains of stopping female genital mutilation.

“Why cut at all? There is no reason why this part of the woman’s body should be cut. There is no justification for it.We need to put a surveillance system in place at the community level and healthcare level. Prosecution is also difficult as only 11 states have laws banning female genital mutilation.

“We call on the Medical and Dental Council of Nigeria (MDCN), midwives and other regulatory bodies to fish out the perpetrators. We all have to be part of the grand movement to stop the medicalisation of female genital mutilation”

Minister of Health, Prof Isaac Adewole, who was represented by Dr Kayode Afolabi , Head, Reproductive Health Division of the ministry at a workshop on female genital mutilation recently said there was a wrong belief among the populace that female genital mutilation is acceptable if it is performed by a doctor, nurse or other healthcare professionals.

“Female genital mutilation is being hospitalized. This is a big problem. Medicalization is of concern all over the country because people tend to believe that once it is done by maybe a doctor or nurse it is justified. The issue is far beyond hygiene or immediate complications. It is time to commit resources, and funding to end medicalisation of female genital mutilation,” he said.

He said the Violence Against Persons Prohibition Act (VAPP) of 2015 criminalises female genital mutilation and any doctor or health professional caught engaging in it will be prosecuted .

“The VAPP law completely outlaws female genital mutilation of any form. Since female genital mutilation is outlawed, it also covers whether is done by a health provider or by a non-qualified traditional provider. It has short and long term effects that is why it needs to stop. It is also an infringement of the women who are exposed to such mutilation.”

However, he added that it is a national law and needs to be domesticated at the state level. “It is operational in the Federal Capital Territory (FCT) and a few states, other states need to domesticate it. There should be implementation at every level, so that the practice will be phased out in the country.”

He said government was working towards a review of curricular of training institutions for health workers to emphasize that female genital mutilation is outlawed, and to also link it to the issuance of practicing licenses to healthcare providers.

Acting representative of the United Nations Population Fund (UNFPA) Nigeria, Dr Eugene Kongnyuy, said Nigeria constitutes at least 10% of the burden of the female genital mutilation globally. He added that about 13% percent of the practice in the country is done by health professionals.

He said, “Out of 200 million women with female genital mutilation, Nigeria accounts for 20 million women. Also 25% of women in Nigeria have undergone female genital mutilation. About 12.7 to 13% percent of female genital mutilation is actually done by health professionals in Nigeria; that to me is unacceptable, and the justification could be that well ‘if it is done by a medical professional then it is less risky. That is not a justification, there is no medical reason or benefits for female genital mutilation”.

President of the International Federation of Female Lawyers (FIDA), Federal Capital Territory chapter, Barrister Ikenga Ngozi, stressed the need for all states to operationalize the VAPP.

She called on health professionals to advise parents and people who bring their girls to them at home for ‘circumcision’ to reject the money, and educate them on the implications of what they intend doing to their daughters .

She also enjoined Nigerians to always report people who engage in the practice to appropriate authorities.