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1. Female genital mutilation - an exported medical hazard.............................................................................. 1

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Female genital mutilation - an exported medical hazard

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Abstrak: Female circumcision (FC) has remained a common practice in the countries where it has traditionally
been performed. Following increased global mobility, it has also become a common medical issue in the
predominantly non-Islamic countries where an increasing number of immigrants from regions where FC is still
traditional, have settled. To investigate types of FC found in a group of immigrants from northern Africa with a
current domicile in Scandinavia. To characterize these women with regard to education, socio-economic status
and experienced complications and sequelae. To report attitudes to FC among the women and their husbands.
An autoquestionnaire was distributed to 220 immigrant women (16-42 years old), who belonged to an African
community in Scandinavia and who had all been circumcised. Information was also gathered concerning 76 of
their daughters (aged 1-13 years). Of the women's husbands, 95 were asked about their attitudes to FC. Of the
140 women, who had been circumcised in their home country before they migrated, 78 (35%) had been
clitoridectomized, 38 (17%) had been subjected to genital excision and 24 (11%) to infibulation. The
corresponding percentages in the remaining women, who had had FC when returning home for a visit, were
0%, 14% and 22%, respectively. Of the daughters, 15 (19%) had been circumcised whilst living in Scandinavia;
all had been clitoridectomized. Twenty-eight (13%) women reported having experienced late complications or
post-FC sequelae. A positive attitude to stopping the tradition of FC was reported twice as often by the
husbands (69%) as by the circumcised women (35%). Religion (95% of the responders were Muslims and 5%
Christians), cultural tradition, and increased chance of marriage or of continued health were the reasons put
forward in favor of the continuation of FC by 58%, 27%, 10% and 4 %, respectively. Five per cent could not
supply an opinion. FC is performed in immigrant women even after settling in areas where this practise is legally
banned. Circumcised immigrant women experience medical and sexual problems which have to be dealt with in
their new domicile country. Many African Islamic women, who have migrated to Scandinavia, seem still to be in
favour of the continuation of circumcision for varying reasons.
Teks lengkap: Headnote
ABSTRACT
Background Female circumcision (FC) has remained a common practice in the countries where it has
traditionally been performed. Following increased global mobility, it has also become a common medical issue
in the predominantly non-Islamic countries where an increasing number of immigrants from regions where FC is
still traditional, have settled.
Objectives To investigate types of FC found in a group of immigrants from northern Africa with a current
domicile in Scandinavia. To characterize these women with regard to education, socio-economic status and
experienced complications and sequelae. To report attitudes to FC among the women and their husbands.
Methods An autoquestionnaire was distributed to 220 immigrant women (16-42 years old), who belonged to an
African community in Scandinavia and who had all been circumcised. Information was also gathered concerning
76 of their daughters (aged 1-13 years). Of the women's husbands, 95 were asked about their attitudes to FC.
Results Of the 140 women, who had been circumcised in their home country before they migrated, 78 (35%)
had been clitoridectomized, 38 (17%) had been subjected to genital excision and 24 (11%) to infibulation. The
corresponding percentages in the remaining women, who had had FC when returning home for a visit, were
0%, 14% and 22%, respectively. Of the daughters, 15 (19%) had been circumcised whilst living in Scandinavia;
all had been clitoridectomized. Twenty-eight (13%) women reported having experienced late complications or
post-FC sequelae. A positive attitude to stopping the tradition of FC was reported twice as often by the
husbands (69%) as by the circumcised women (35%). Religion (95% of the responders were Muslims and 5%
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Christians), cultural tradition, and increased chance of marriage or of continued health were the reasons put
forward in favor of the continuation of FC by 58%, 27%, 10% and 4 %, respectively. Five per cent could not
supply an opinion.
Conclusions FC is performed in immigrant women even after settling in areas where this practise is legally
banned. Circumcised immigrant women experience medical and sexual problems which have to be dealt with in
their new domicile country. Many African Islamic women, who have migrated to Scandinavia, seem still to be in
favour of the continuation of circumcision for varying reasons.
KEYWORDS
Mutilation, Circumcision, Females
INTRODUCTION
In 1995, the World Health Organization (WHO) defined female genital circumcision (FC) or mutilation as 'all
procedures involving partial or total removal of the external female genitalia or other injury of the female genital
organs whether of cultural, religious, or other non-therapeutic reasons'. At the time, WHO estimated that FC
was performed on two million women annually. In spite of many efforts to stop FC by official and nongovernmental organizations, the habit has remained common, not least in northern Africa from where our
female study population stemmed1-10.
Classically, three types of FC have been recognized, i.e. clitoritidectomy (sunna), involving removal of a part of
the clitoris or the whole organ; excision, where the clitoris and part of the labia minora and majora are excised;
and infibulation, where also the two sides of the vulva are sewn together, except for a small opening to permit
the passage of urine and menstrual blood.
A large number of acute complications of FC are seen, such as bleeding, local and general infections, as well
as the occurrence of gynecological, obstetric and urological sequelae11-16. Already a decade ago, WHO
estimated that the health of more than 100 million women had been impaired by FC.
The present study presents data obtained by interviewing female emigrants from northern Africa who had
migrated to Scandinavia and who had been circumcised. Data concerning a group of their daughters subjected
to FC after they had arrived in their new domicile are also reported, as well as their age at the procedure, the
type of mutilation, complications, beliefs and attitudes concerning FC.
MATERIALS AND METHODS
An autoquestionnaire was distributed to 220 African women who had all been subjected to FC. The response
rate was 100%. Illiterate women received help with filling in the questionnaire. The women also answered
questions concerning their 76 daughters who had had been born after the parents' immigration. In addition, 95
husbands were interviewed about their attitude to FC. The responders were members of the same union in
Scandinavia where they had settled. They were recruited by one of us (E.M.), who personally knew the families.
The women's ages ranged from 16 to 42 years (median 20.5 years). Questions concerned age at the FC
procedure, place of performance, education, religion, current socioeconomic status, early and late gynecological
and obstetric complications and sequelae of FC, as well as attitudes and beliefs concerning reasons for FC.
Permission to conduct the study was obtained from African Community Boards in Sweden.
RESULTS
Type of circumcision, site of performance and age at the procedure
In 140 (64%) of the 220 women, the FC had been performed whilst they were still living in their native country.
Clitoridectomy was the most common procedure, followed by excision and infibulation (Table 1). Fifteen (19%)
of the 76 daughters had also been circumcised, all of whom were clitoridectomized. The ages of the women
when the circumcision was performed, are shown in Figure 1; the mean age was 7 years (range 1-15 years).
Education and employment
The education history of the women is shown in Table 2. Almost half of them had had no school education. Of
the daughters, 12% had illiterate mothers, whilst only 4% had mothers who had passed secondary school.
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Of the women, 46% were unemployed, 23% were labourer's, 12% were students, 11% were civil servants,
whilst 8% had a professional occupation.
Complications and sequelae of FC
Twenty-two (10%) of the women remembered, or more often had been told by their mothers, that there were
immediate post-FC complications, e.g. severe hemorrhage, delayed wound healing, local infections, urinary
tract infection, septicemia. Twenty-eight women (13%) reported late complications experienced by themselves,
e.g. cyst- and keloid formations and recurrent local infections. Dyspareunia was a common complaint.
Caesarean section, as a result of changed anatomical conditions caused by the circumcision, was performed in
six women (3%).

Beliefs and attitudes concerning FC

The beliefs of the women and the 95 husbands as to why FC is performed and if it should or should not be
continued are shown in Table 3. More than half believed that their religion required FC to be performed, while
approximately one-quarter believed that it was merely a cultural tradition. An increased chance of marriage and
of remaining healthy, and the prevention of promiscuity were other indicated reasons for FC.
In Table 4 different attitudes towards the tradition of FC are listed, both among the women and 95 of their
husbands. The percentage of men that believed FC should be discontinued was twice that of the women. None
of the husbands indicated that FC should be continued as performed at present. Approximately one-third of the
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women were of the opinion that if continued, the procedure should be less extensive.
DISCUSSION
Several studies performed in northern Africa have shown that the practice of FC is still common. A study from
Nigeria reported that over half of the study population of females was circumcised10. In a cohort of Sudanese
university students, 56.8% had been subjected to FC9. The prevalence of circumcised women and beliefs and
attititudes concerning FC among immigrants must be considered when analyzing FC among women who have
emigrated from this area of Africa.
This study reports from an African community of individuals who have immigrated to Scandinavia. FC is
commonly found in this community. Clitoridectomy was the predominant type of FC, which most often had been
performed in their native country. However, FC had also been performed in 10% of their daughters after the
emigration, which was reported to have been undertaken on revisits to their native country.
There was no drop out from those asked to participate. This was also the case among the husbands who had
been requested to take part in the study. This circumstance is to be regarded in the light of its character as an
'inside study', not one performed by an external body.
The percentage of early post-FC complications of 10% most probably represents a minimum figure as the
information predominantly came from what the responders had heard from their mothers. One late, often
overlooked, result of FC is that some women refrain from consulting gynecologists or other physicians, because
they do not want to disclose that they have been circumcised, which they think may result in humiliation.
The most common belief among many groups of immigrants from countries where FC is traditionally performed,
is that FC is requested as part of the Islamic religion, even if it is not in the Koran. FC was practised in some
pre-Islamic Arabic Cultures17. In our study population there were also some Christian women who were
circumcised.
To increase a daughter's future chances of finding a husband was one of the reasons put forward for the
performance of FC. Of the women in our study, 10% had this belief. A similar percentage was reported by
female university students in Khartoum9.

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Of male university students in Khartoum, 74.8% preferred a non-circumcised life partner. A similar percentage
in that study thought that if FC was to be practised, it should be with clitoridectomy and not by infibulation. In our
study with many Sudaneses participants, a majority expressed that the practice of FC should be stopped. As in
the Sudanese study, many (approximately one-quarter) expressed the view that if continued it should be
modified to avoid infibulation.
It could be possible that certain groups, i.e. physicians, birth attendants, nurses and midwives, support the
continuation of FC for their own economic purposes. In an Egyptian study4, the percentage of doctors
confessing to participating in FC was found to have increased. Indeed the practise of FC did not decrease but
instead increased during 1980s and 1990s and despite many pleas for its banning5,18,19, the practice has
continued.
The extent of FC performed in Europe is not known but a number of European countries have proclaimed FC
illegal20, such as Great Britain, France, Germany and Sweden. At present, the EC has economically supported
a project to investigate the extent of FC among its inhabitants.
Physicians in predominantly non-Islamic countries, such as Scandinavia, have in recent years been more
commonly confronted with patients suffering the complications and sequelae of FC from the growing immigrant
communities. The percentage of women who have experienced such problems in our study does not seem to
differ from previous studies of PC.13,14. Problems encountered include gynecological problems, such as
genital and urinary tract infections, and obstetric complications during the gestational period and at delivery.
Another post-FC problem is related to menstrual hygiene. Still another problem is severe dyspareunia, which
creates sexual problems in many circumcised women; a problem seldom discussed by the women at
consultation.
In the past, FC was even regarded as a means to cure insanity, epilepsy, catalepsy and hysteria21. A more
recent misunderstanding is that FC will decrease the transmission of human immunodeficiency virus22. In the
light of these views, some progress may have been made, but even so, our study illustrates the fact that
substantial impact remains, primarily regarding maternal beliefs and attitudes, if the practice of female
circumcision is to be abolished.
References
REFERENCES
1. Eldareer A. Epidemiology of female circumcision in the Sudan. Trop Dort 1983;13:41-5
2. Onadeko MO, Adekunle LV. Female circumcision in Nigeria. A fact or farce? J Trop Pediatrics 1985;31:180-4
3. Dine M. Female circumcision in Somalia and women's motives. Acta Obstet Cynecol Scand 1991;70:581-5
4. Hussein A. Female genital mutilation: the road to success in Egypt. Plan Parent Chall 1993;2:40-2
5. Gamble A. Stopping female mutilation. An update. Freedom Rev 1995;26:22-3
6. Hassan A. Sudanese woman's struggle to eliminate harmful practices. Plan Parent Chall 1995;2:17-8, 21-2
7. Magoha A, Magoha OB. Current global status of female genital mutilation: a review. East Afr Med J
2000;77:268-72
8. Briggs LA. Male and female viewpoints on female circumstances in Ekpeye, River State, Nigeria. Afr J
Reprod Health 2002;6:44-52
9. Hericka E, Djar J. Female genital mutilation in the Sudan: survey of the attitude of Khartoum university
students towards this practice. Sex Trans Inf 2003;79:220-3
10. Ogunlola IO, Orji EO, Owolabi AT. Female genital mutilation and the unborn female child in southwest
Nigeria. J Obstet Gynecol 2003;23:143-5
11. Aziz FA. Gynecological and obstetrical complications of female circumcision. Gytiecol Obstet 1980;17:560-3
12. Anonymous. A traditional practice that threatens health-female circumcision. WHO Chron 1986;40:31-6
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13. Shandall AA. Circumcision and infibulation. Sudan Med J 1967;5:178-212

14. Verzin JA. Sequelae of female circumcision. Trop Dort 1975;5:163-9
15. Toubia N. Female circumcision as a public health issue. New Engl J Med 1994;331:712-6
16. McCaffrey M. Female genital mutilation: consequences for reproductive and sexual health. Sex Marital Ther
1995;10:189-2000
17. Levy R. The social structure of Islam. Cambridge Univ Press, 1957
18. Toubia N. Female genital mutilation: A call for global action. New York: Woman Ink, 1993
19. Mbugua I. Ending the mutilation. People Planet 1997;6:17-9
20. Dorekenoo E, Elworthy S. Female genital mutilation: proposals for change. London: Minority Rights Group
International, 1992
21. Brown IB. On the curability of certain forms of insanity, epilepsy, catalepsy and hysteria in females. Br Med
J 1866;1:675-8
22. Hardy DB. Cultural practices contributing to the transmission of human immunodeficiency virus in Africa.
Rev Infect Dis 1987;9:1109-19
AuthorAffiliation
Mahoud Elgaali, Helena Strevens and Per-Anders Mdh
Department of Obstetrics and Gynecology, Lund University, Lund, Sweden
AuthorAffiliation
Correspondence: Prof. P.-A. Mrdh, Department of Obstetrics and Gynecology, Lund University, SE-22185
Lund, Sweden
MS 316
205 European Society of Contraception
DOI: 10.1080/13625180400020945
Subjek: Female circumcision; Health hazards; Aliens; Women; Attitudes;
MeSH: Adolescent, Adult, Africa, Northern -- ethnology, Attitude to Health, Child, Child, Preschool,
Circumcision, Female -- adverse effects, Circumcision, Female -- psychology, Circumcision, Female -- statistics
& numerical data, Culture, Emigration & Immigration, Female, Humans, Infant, Male, Questionnaires, Religion,
Scandinavia -- epidemiology, Sex Factors
Lokasi: Scandinavia, North Africa
Judul: Female genital mutilation - an exported medical hazard
Pengarang: Elgaali, Mahoud; Strevens, Helena; Per-Anders Mrdh
Judul publikasi: European Journal of Contraception & Reproductive Health Care
Volume: 10
Edisi: 2
Halaman: 93-7
Jumlah halaman: 5
Tahun publikasi: 2005
Tanggal publikasi: Jun 2005
Tahun: 2005
Penerbit: Taylor & Francis Ltd.

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Tempat publikasi: Carnforth

Negara publikasi: United Kingdom
Subjek publikasi: Medical Sciences--Obstetrics And Gynecology
ISSN: 13625187
CODEN: ECRCFK
Jenis sumber: Scholarly Journals
Bahasa publikasi: English
Jenis dokumen: Feature, Journal Article
Fitur dokumen: Tables Graphs References
Nomor aksesi: 16147813
ID dokumen ProQuest: 200706004
URL Dokumen: http://search.proquest.com/docview/200706004?accountid=36184
Hak cipta: Copyright CRC Press Jun 2005
Terakhir diperbarui: 2011-08-30
Basis data: ProQuest Research Library

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