FGM Awareness Programme
ACCM (UK) evolved from a major charity, Agency for Culture and Change Management - Sheffield, whose primary role was to lobby for and communicate the effects of legislation concerning Female Genital Mutilation and other harmful traditional practices in the UK. The primary function of ACCM (UK) is to expand this work in the new legal framework and to look at the wider issues that affect minority and other vulnerable communities including tackling health, social and economic inequalities at a local level.
Since 2009, it has been developing FGM awareness work in East of England, Bedfordshire, Luton, Buckinghamshire and Northamptonshire. Work in the new Regions has been around reaching to grassroots communities to empower them with information, human rights, parenting and the legal and Safeguarding implications.
ACCM (UK) also works with professionals and service providers to ensure that they are sensitised to enable them to tackle the practice in a holistic way to help victims of FGM and protect those at risk without being seen to offend the communities concerned.
ACCM (UK) strongly believes that use of sensitive and appropriate terminology is the key to engaging with communities on such an emotive and sensitive issue of FGM. Grassroots communities will listen and take advice if they feel that they are being respected, empowered and not offended.
ACCM (UK)'s methods are far different from other campaigners as we concentrate on the needs of victims of FGM and protecting those at risk working at grassroots level with communities themselves as the driving force behind our work. Our campaigns are low key as we want to engage more with communities and rarely get involved in mass media in order to undermine the trust and confidence we have built with communities around the UK.
During our period of campaigning to eliminate FGM our reputation for sensitivity, experience and professionalism in running events or workshops, giving information, supporting and advocating for girls and women victims of FGM experiencing health complications or family distress from FGM is highly regarded.
Our methods using development approached enables full consultations, involvement and engaging with grassroots communities who are at the forefront of our work from planning, organisation and running of events or workshops for the community, health professionals, Safeguarding Teams including the Police, schools and other agencies including service providers. Because practicing communities are at the forefront of our campaign they make decisions on approaches, review our progress and act as advocates to other community members.
ACCM (UK) strongly beliefs young people are the key to elimination of FGM not just in the UK but in other practicing countries if supported. We work well with young people whom we recruit, train and support to act as peers to other young people. We have also helped other groups of young people, such as the Integrate Bristol, to set up and develop their campaigns.
What is FGM
In spite of laws and serious campaigns against female genital mutilation (FGM) also known as female cutting or circumcision (FC), this ill-treatment continues in many parts of Africa, Europe and around the world. Different organisations working against the practice, stress the need to provide awareness raising and provision of information on the severe implications this tradition impacts on girls and women. The practice tends to go underground when its only limitation rests on the law.
The World Health Organization (WHO, 1997) defined female genital mutilation (FGM) as all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or other non-therapeutic reasons.
A joint research between the United Nations (UN) and the World Health Organisation (WHO) they found that there were many different forms of FGM and the WHO decided to simplify the different forms by classifying it into four types:
Type I. Clitoridectomy or excision of the prepuce, with or without excision of part or all of the clitoris.
Type II. Excision of the clitoris with partial or total excision of the labia minora.
Type III. Excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation).
Type IV. Unclassified: this includes pricking, piercing or incising of the clitoris and/or labia; stretching of the clitoris and/or labia cauterization by burning of the clitoris and surrounding tissue.
The most commonly practiced genital mutilation types are clitoridectomy and excision comprising of about 85% in Africa. Although genital mutilation is practiced in mostly Islamic countries it is not an exclusively Islamic practice. It is in fact a pre-Islamic cultural practice not found in much of the Middle East Islamic countries. Female genital mutilation is cross-cultural and across tribal whereby in Africa and some parts of the Middle East it is practiced by Moslems, members of the various Christian religions including protestants, Catholics (Sierra Leone) and Jews (Ethiopia) and non-religious communities alike.
Female Genital Mutilation Types
Female Genital Mutilation (FGM), also known as female circumcision, or female genital cutting, has been practiced for several thousand years in almost 30 African and Middle Eastern nations. It is also practiced, to a lesser extent, in parts of Asia and Middle East. FGM is not a religious obligation as some practicing communities think but is wide spread and practiced amongst Muslims, Christians, Jews, followers of traditional African religions and non religious communities
Background to FGM
It is not known when and where it originated from but it is presumed to have started around 400 BC. It has been traced back to three centuries to African communities, pre-Islamic Arabs, Tsarist Russia and ancient Egyptian Aristocracy. Female genital mutilation was originally practised to control female sexuality and various other methods were used including the chastity belt, the Romans put rings into labia majora of female slaves. Because of the predominance of the practice being concentrated in the Central, North and East Africa, Researchers and Anthropologists believe it may have originated from these parts. It is believed to have originally been started my men in primitive societies to control their women's sexuality.
How the practise of carried out
The way the practice is carried out varies from community to community, tribe to tribe even amongst families. It is often argued that it is the mother, grandmother or other elderly female relatives who will decide what form or type of circumcision the child will undergo. In most cases it may also depend on the circumciser or practitioner performing the circumcision.
In rural settings older women in the villages usually carry out FGM. They have no medical training in surgical practices. Midwives and traditional birth attendants sometimes perform the operation. In a few places, such as Egypt and the northern part of Nigeria, male village barbers sometimes perform the operation.
In urban areas trained doctors, nurses and midwives are performing FGM much more frequently with anaesthetics in hospitals especially in Sudan (Naheed, Comfort). This medicalisation of FGM has been condemned as this is seen to ingrain FGM and make it acceptable to communities that practice it. The health professionals should be campaigning and putting strategies in place to stop it and not to make accessible by providing hygienic or non painful facilities to promote the practice.
Anaesthetics and antiseptics are not generally used and pastes containing herbs, local porridge, or ashes are frequently rubbed on to the wound to stop bleeding. The girl or woman may be made to sit in a bath or river of cold water to nab the genital area to anaesthetise the area before operation. The girl is often held down by female relatives to prevent her from struggling and there is often unintended damage due to crude tools, poor light and septic conditions. Sometimes herbs are put on the tongue so that it will retract and the girl will not bite it off due to the excruciating pain.
A variety of instruments are used to perform FGM, depending on the country and the group involved. Special knives may be used. For example, special saw –toothed knives are used in Mali. Razors are commonly used as well as scissors, pieces of glass, and even on rare occasions, sharp stones, in some countries. Fingernails are sometimes used in the Gambia to pluck the clitoris of babies (Comfort, WHO).
In villages the instruments used to perform FGM are not sterile. Often many girls are operated on during a single ritual ceremony. In these cases the same razor or knife is commonly used on a number of girls increasing the risk of the transmission of STIs and HIV / AIDS.
Age of girls / women
FGM can take place at a different age in a girl's or woman's life depending on the country, ethnic group, family etc. It may vary among different groups in the same area of the country. For example, the Ethiopian Falashas perform the operation when the baby is a few days old. In Egypt the girl is generally between seven and ten years old. In other groups the ceremony may not occur until the girl is of marriageable age, approximately 14 to 16 years of age. The most typical age for infibulation seems to be between 4 and 8, although the age is generally falling – indicating that FGM is having less and less to do with initiation into adulthood. In the UK NGO's and professionals campaigning against the practice argue that the age when female children are circumcise is falling due to the fact that parents and families are aware schools are monitoring children and they are doing it before children start school to invade the law (ACCM, Comfort etc). Marwa Ahmed (Comfort 2005) stated that majority of the women she interviewd have had FGM done in their country of origin regardless of whether they were British born with highest number circumcised while aged 6 years old.
The lowering of the age at which the operation is performed could also be attributable to the increased awareness of the condemnation of the practice and the laws prohibiting it, both in African countries and in countries where refugees and other immigrants have settled. Professional bodies and NGOs and campaigners are now very much aware of the implications and girls and young women are now being monitored especially in schools forcing parents to now perform FGM to girls before they start school. ACCM campaigning at the grassroots argues that girls are no longer being subjected to Type III or II but are now going through Type I or Sunna as the practice is very mild and does not leave sever health or social implications that can be noticed (ACCM, Comfort, LBWHA).
CONSEQUENCES AND HEALTH IMPLICATIONS OF FGM
Facts about FGM
Many women appear to be unaware of the relation between FGM and its health consequences; in particular the complications affecting sexual intercourse and childbirth which occur many years after mutilation has taken place. This is because women have been conditioned socially to accept the practice and the pain that goes with it, as it is seen as part of being a woman or growing up.
FGM can have devastating long term harmful consequences for a woman throughout her life. The health problems a girl or woman will experience as a result of the operation depend on a number of factors including: the severity of the operation, the sanitary conditions in which it was performed, the competence of the person who performed it and the extent of the girls' resistance. The most detrimental health consequences occur with Type III or infibulation.
IMMEDIATE OR SHORT TERM COMPLICATIONS
Haemorrhage - This is one of the most common complications of FGM, as excision of the clitoris involves cutting across the higher-pressure clitoral artery and attempts to stop bleeding may not be effective. Secondary haemorrhage may occur after the first week as a result of sloughing of the clot over the artery due to infection. Cutting of the labia causes further damage to the blood vessels and Bartholin glands. Acute extensive bleeding can lead to haemorrhagic shock or even sudden death.
Shock - This may occur because of blood loss (haemorrhagic shock) and the severe pain and trauma (neurogenic shock) of the procedure, which is performed without any medication or anaesthetic. Both can be fatal.
Acute urine retention - Retention is very common and may last for hours or days, but is usually reversible. It is usually due to pain, tissue swelling, inflammation injury to the urethra, or pain of passing urine on the raw wound. This condition often leads to urinary tract infection.
Fracture or dislocation - Fractures of the clavicle, femur humorous or hip joint can occur in girls who struggle violently while being held down by several adults. This leads to long-term severe pelvic and tissue inflammation and back pain.
Damage to other organs - Injury to the urethra, vagina perineum and rectum can result from the use of crude instruments, poor lights, careless techniques, or from the struggles of the girl. The circumciser is not a medically trained person and can be an old woman who may be partially blind.
Infections - This is commonly caused by the unhygienic conditions in which FGM is performed, the use of non-sterile or poorly disinfected or dirty equipment, applications of traditional herbs or ashes to the wound, contamination of the wound with urine and / or faeces, or binding of the legs following infibulation, which prevents wound drainage. Septicaemia or tetanus may develop. The wounds may fail to heal quickly because of infection, irritation from urine, underlying anaemia, or malnutrition.
LONG TERM COMPLICATIONS
Difficulty in passing urine- This can be due to damage to the urethral opening, obstruction of the urinary opening, or scarring of the meatus – and can lead to chronic incontinence or difficulty passing urine. For many infibulated girls, urinating can take up to 20 minutes when they are still virgins.
Recurrent urinary tract infections - Partial closure of the vagina and urethra results in the perineum remaining constantly wet and susceptible to bacterial growth. Retrograde Urinary Tract Infections (UTIs) therefore commonly occur, affecting the bladder, uterus and kidneys. Damage to the lower urinary tract during the procedure can also result in urinary tract infection. If substances were put underneath before infibulation, they will remain causing absences or infections.
Chronic pelvic infections - Partial closure of the vagina and urethra increases the likelihood of infection and ascending pelvic infections are common. The infections are often painful and may be accompanied by noxious discharge spreading to the uterus, fallopian tubes and ovaries – and frequently became chronic.
Infertility - This can occur due to chronic pelvic infections causing irreparable damage to the 4 reproductive organs.
Vulva Abscesses - These develop due to deep infection resulting from faulty healing or an embedded stick or substances that were used to stop the bleeding or help healing causing the formation of an abscess.
Nerinoma - This can develop when the dorsal nerve of the clitoris is cut or trapped in a stitch or in scar tissue. The surrounding area becomes hypersensitive and unbearably painful.
Keloid Scar - These result from slow and incomplete healing of the wound and the production of excess scar tissue. The scars may obstruct the vaginal orifice and be so extensive that they prevent penile penetration.
Dermoid Cysts - These result form inclusion of the epithelium (various layers of tissue) during healing, leading to swelling or pockets producing secretion. The cysts vary in size, are extremely painful and can prevent sexual intercourse.
Calculus Formation - These develop due to menstrual debris or urinary deposits in the vagina or in the space behind the bridge of the scar tissue.
Vaginal Fistulae – Vesico - Vaginal fistulae can form as a result of injury during mutilation, de-infibulation, re-infibulation, sexual intercourse, or obstructed labour. Urinary and faecal incontinence may be life long with severe social consequences.
Difficulties with Menstruation - Partial or total closure of the vaginal opening commonly results in painful menstruation or abnormal absence of menstruation. Haematocolpos occasionally occurs from the retention of menstrual blood when there is almost complete closure of the labia due to stitching.
Increased Risks of HIV Transmission - There is an increased risk of HIV transmission due to the use of the same un-sterile instruments in-group mutilations. Often even in single mutilation, the same instrument is used on several girls before it is replaced for economic reasons.
Problems in Pregnancy and Childbirth - Problems during pregnancy and childbirth are very common, particularly following infibulation. The extent of the complications varies depending on factors such as the size of the opening, parity and the nature of the scar tissue. The most common complications following infibulation are as follows:
Sexual, Psychological and Social Consequences of FGM - initial sexual intercourse through the reduced and damaged genital nerve and scar tissue can be impossible or difficult without further tissue damage. Re-cutting the tissue (de-infibulation) is often necessary. In some communities husbands are expected to forcefully penetrate to enlarge the opening, which is extremely painful, and consummation of marriage may take months if the scar tissue doesn't heal quickly.
There is a doctor in France with a team who have made claim to being able to reconstruct the damaged clitoris from psychological reason to the women but critics argue that this still amount to performing FGM again on women. There is no review of this surgery and whether it has been a success (FGM EuroNetwork Conference 2007)
Mental and Social Consequences - FGM is generally performed when girls are quite young and uninformed. It is often preceded by acts of deception, intimidation, coercion and violence by trusted parents, relatives and friends. Girls are usually conscious when it is performed with no anaesthesia or medication given and they have to be physically restrained by four to five female adults. It is not surprising that the experience becomes a vivid landmark in their mental development with feelings of deep anger, fear, bitterness and betrayal at having been subjected to such pain. For some girls and women the physical and psychological experience of female genital mutilation is extremely traumatic and long life lasting. The experience is commonly associated with flashbacks and posttraumatic stress, mental health problems, symptoms and disorders that affect a wide range of brain functions.