Female Genital Mutilation: A Violence against women and women’s Health

The origin of female genital mutilation (FGM) is not known but shrouded in secrecy and confusion [1]. Female Genital Mutilation is defined by the World Health Organization (WHO) as all procedures which involve partial or total removal of female external genital or other injuries to the female genital organs for cultural or non therapeutic reasons [2]. It is a global phenomenon with no exception of any continent, the practice metastasis beyond cultural, ethnic, social or religious boundaries [3]. However, it is found mostly in 27 African Countries, and also in Indonesia, Iraq Kurdistan and Yemen [4]. It is also found in other communities in the world where these ethnicities are domiciled. The highest prevalence is seen in Somalia (98%), Guinea 97% and Djibouti but Nigeria, though with national prevalence of 41% has the highest absolute number of women/ girls who had FGM [4-6]. In Nigeria, the practice is commoner in the South-East (63.3%), SouthWest (53.2%) and the least 13% in the Northern Nigeria, though with the most severe forms of FGM [7-9]. Most African countries including Nigeria, and other regions in the middle East where FGM is concentrated has passed laws restricting FGM and studies have also shown a decline in regional FGM [4], but the long term impact on those who have had it and immediate psychological and health complications on those who are at risk of being genitally mutilated annually is of critical concern to all mankind and nations that uphold the sanity of human right, therefore the need for this review.


Introduction
The origin of female genital mutilation (FGM) is not known but shrouded in secrecy and confusion [1]. Female Genital Mutilation is defined by the World Health Organization (WHO) as all procedures which involve partial or total removal of female external genital or other injuries to the female genital organs for cultural or non therapeutic reasons [2]. It is a global phenomenon with no exception of any continent, the practice metastasis beyond cultural, ethnic, social or religious boundaries [3]. However, it is found mostly in 27 African Countries, and also in Indonesia, Iraq Kurdistan and Yemen [4]. It is also found in other communities in the world where these ethnicities are domiciled. The highest prevalence is seen in Somalia (98%), Guinea 97% and Djibouti but Nigeria, though with national prevalence of 41% has the highest absolute number of women/ girls who had FGM [4][5][6]. In Nigeria, the practice is commoner in the South-East (63.3%), South-West (53.2%) and the least 13% in the Northern Nigeria, though with the most severe forms of FGM [7][8][9]. Most African countries including Nigeria, and other regions in the middle East where FGM is concentrated has passed laws restricting FGM and studies have also shown a decline in regional FGM [4], but the long term impact on those who have had it and immediate psychological and health complications on those who are at risk of being genitally mutilated annually is of critical concern to all mankind and nations that uphold the sanity of human right, therefore the need for this review.

Classification of FGM
Several forms of FGM are practiced in the world today and they vary according to culture and ethnic groups. The WHO recognized four types: Type I (Sunna) refers to excision of the prepuce with or without the tip of the clitoris. Type II refers to removal of clitoris together with partial or total removal of the libia minora with or without excision of the labia majora. Type III; infibulations, involve excision of all or part of the external genitalia with or without narrowing of the vagina, having a small hole for urination and passage of menstrual fluid. Type IV includes other various practices in the genital area with varying degrees of severity for non therapeutic purposes. These include piercing, stretching, cauterizing the clitoris, gishiri cut, introduction of corrosive substances in the vagina etc.

Reasons for FGM
Most communities and cultures that practice FGM defend with passion and give reasons why the practice must be perpetuated. Some of the reasons include acceptability of a girl as a marriageable female, ethnic identity, purification and maintenance of virginity and improvement of fertility. Other reasons are enhancement of male sexual pleasure, prevention of promiscuity in marriage, aesthetic appeals to the female external genitalia and enhancement of child survival. Some cultures have no clear reason for the practice [1,10,[13][14][15].

Medical complications of FGM
FGM has no known health benefits, the health consequences may depend on the type, severity, the circumciser, instrument used and what is applied after the procedure. FGM is known to inflict physical and emotional pain to the female of which magnitude has not been fully quantified [16]. Other complications include hemorrhage, recurrent infections, urinary retention, anemia, scar or keliod formation, gynatresia, infertility, vesicovaginal fistula (VVF), rectovaginal fistula (RVF), aparunia and dysparunia [1,[17][18][19][20][21]. Obstetric complications also include perineal lacerations, higher rates of episiotomy, delay in second stage of labour, caesarean deliveries, neonatal resuscitation, fresh still births and primary post partum hemorrhage(PPH) [16,22,23]. Psychiatric disorders have been noted also and contraction of HIV and Hepatitis B viral infections especially during group circumcision and use of unsterilized instruments or one instrument for many girls [21,[23][24][25].

Age at which FGM is performed
Most countries perform FGM days after birth to age of puberty, whereas some perform at full adulthood, before marriage or delay until during pregnancy [25,26]. It is usually done by traditional circumcisers who do not have medical knowledge; some are traditional birth attendants, mothers or grandmothers. In some countries health workers including nurses and doctors perform FGM [25][26][27].

Global burden and impact of FGM on human right
UNICEF in 2016 reported that about 200 million women and girls have undergone FGM and at least 2million girls are at risk of been genitally mutilated annually and Nigeria has a quarter of this number. UNICEF expressed concern that if the tempo on the war and interventions against FGM is sustained, about 4.1 million females will be cut annually by 2050 and 130 million girls would have been spared of this obnoxious injury, but if no interventions are provided, the number of girls and women that would have been cut will grow from 133 million in 2013 to 325 million by year 2050 [4,25]. FGM has no health benefit rather subjecting women to often permanent physical and psychological trauma [27]. The magnitude of this trauma is yet to be fully estimated. The extent and complication of the procedure is not often explained to the subject and the right to informed constant is not obtained where the subject is a minor before the procedure and no consideration or explanation is given on the short or long term effects [28,29]. The helplessness and depth of cry of the infant does not modify the extent or severity of the procedure. This cruel act therefore violates the right of the child to be free from torture and inhuman degrading treatment and right to life when the procedure results to death [30]. FGM is recognized globally as a violation of the fundamental human right of girls and women. It reflects extreme inequality and discrimination against women and it intends to control women sexuality and freedom [29][30][31][32]. The Convention on the Elimination of All Forms of Discrimination against Women, against torture, and other cruel, inhuman or degrading treatments or punishment and Convention on the Rights of the Child prohibits the infliction of physical and mental pain or suffering on women and children. The UN world conference on human right recognized FGM as a form of violence against women and human right violation [29]. The UN general assembly also declared war on elimination of violence against women and declared every February 6 as a day of zero tolerance for FGM [4,33,34].
The number of at risk females, with the current level of intervention is unacceptably high. Moreover, due to the growing global population if the level of the intervention is reduced, it will amount to a global injustice against the woman race because the number of girls/women that would be exposed to physical and psychological torture and trauma would be geometrically high. The level of global intervention is therefore inadequate and needs to be scaled-up.

Violence against women
FGM is described also as a training ground for male violence 35. One of the major reasons given by most practicing communities for FGM is to enhance male sexual pleasure and FGM in a known cause of dysparunia [16,35]. Males in such communities may be aware of the pains inflicted to the females for their sexual pleasure and satisfaction with no regard to the terror unleashed to the females during sexual intercourse. This may be viewed as sexual violence or another form of rape.
Women with FGM have more perineal lacerations, episiotomies, primary postpartum hemorrhage and caesarean deliveries than others [16,22,36]. So women with FGM are more likely to have painful puerperium against the joy of motherhood due to the perineal lacerations and episiotomies and perhaps more likely to have maternal mortality from PPH following a severe perineal laceration. The trauma of infertility following recurrent infections observed in some patients with FGM is not easily quantified and the cost of treatment of infertility is high in every part of the world. So the untold hardship on these women especially from poor African countries could be exceedingly high and may lead to marital disharmony and divorce.

Journal of Gynecology and Women's Health
FGM is a major form of violence against women and children who are culturally and religiously defenseless and most vulnerable. It is a leading cause of human right abuse and contributes significantly to reproductive health morbidity as well as mortality. The number of the at risk females, with the current level of intervention is unacceptably high. Moreover, due to the growing global population if the level of intervention is reduced, it will amount to a global injustice against the woman race because the number of girls/women that would be exposed to physical and psychological torture and trauma would be geometrically high. The level of global intervention is therefore inadequate and needs to be scaled-up.

Mitigating against FGM
It is obvious that the gravity of the medical and socioeconomic burden of FGM is out of proportion to the current interventions and numerical decline, therefore there is an urgent need for all stakeholders and advocates of human right protection to contribute and scale up support for the eradication of FGM. Education of girl child cannot be over emphasized; Western education, skill acquisition and creation of more vacancies for political positions for women will further empower women to take major steps in mitigating against FGM. Involvement of community and religious leaders is a key to success. FGM is strongly linked to culture and religion, therefore, integration of traditional and religious leaders in the public health education using local languages and dialects to explain the immediate and long term health consequences will drive the message to the target audience and produce the desired effects. Some communities with strong cultural inclination could be encouraged to perform their cultural practices without cutting the genitals. Many African countries where FGM is highly practiced have made laws against FGM but they are poorly enforced. Civil society groups and non-governmental organizations should stimulate the legal system to enforce the laws. FGM and health consequences should be incorporated into the academic curricula of primary and secondary schools health education subject to enable the boy/girl child to be personally convinced beyond tradition, the ills of the practice. International organizations should identify many medical professionals and academicians who have passion for the eradication of FGM to develop other community friendly initiatives that will be more acceptable and effective in the reduction and possibly eliminate FGM in the globe by 2050.

Conclusion
Female genital mutilation is an atypical subject because its general characteristics is yet to be conclusively studied and understood; the origin, cultural and religious inclination has not been clearly revealed so the practice persists despite efforts by local or international organizations. There is a decline but the absolute number continues to increase due to growing global population. Mitigation should follow cultural and religious trends so as to gain acceptability by the people while education and women empowerment will drive along. The involvement of more interest groups with community oriented initiatives in the fight against FGM must be encouraged to increase the scope as to achieve significant decline in the proportion and absolute number of women/girls that underwent FGM before the year 2050.