Awareness of FGM/C and its risk factors is necessary because it allows health pro- fessionals to overcome one of the hurdles to FGM/C identification (Creighton and Hodes 2014). To address this knowledge need, Chaps. 2 and 3 proffered a global evidential synthesis of the prevalence and the mapping of FGM/C. We appreciate that such knowledge was presented in general terms based on countries and regions.
The view now is that it is up to each country to identify particular communities and high-risk groups of individuals who are affected through public health screening of girls in those countries. Thus, general knowledge of FGM/C and provenance and specific information gleaned from the patient may assist health professionals to be able to competently assess their patients in this area of their practice.
4.2.1 What Is FGM/C?
In this section, we give a definition of FGM/C and a general form of arguments used by those who support its practice. We summarise the arguments against it through consideration of health consequences for its victims. The Oxford English Dictionary states that FGM is a traditional practice of cutting off the (usually girl or adult women’s) external genitalia as a cultural or religious rite of passage, for medical or non-medical purposes. We look at what is entailed in this procedure in order to clarify the health and medical issues to which it gives rise.
According to Androus (2004), FGM or female circumcision refers a particular type of surgical change to female genitalia following either the removal of major portions of the genitals, or minor interference with the genitalia in a manner that does not significantly alter the genitalia. The main targets of these procedures are children who for cultural and religious motives who have to undergo a transition from childhood and adulthood. The essence of being a woman in FGM practicing cultures is derived from such a procedure. All that is required is for relatives to con- sult with a traditional surgeon or modern medical professional to accede to the demand of the families of the patient for a fee.
Shweder (2005) concurs that female circumcision refers to the ‘coming of age and gender identity ceremonies involving genital alterations’. Kenyatta (1930, as cited in Shweder 2005) considered female and male circumcision to be an important phase in the transition to adulthood. However, in recent years, under the influence of western feminism, some scholars have come to develop a global discourse of the practice described as female genital mutilation. The phrase ‘female genital mutila- tion’ (FGM) was first coined by Hosken (1993, p. 91). Generally, the matter was not critically studied by anthropologists, who feared potential accusations of ethnocen- tricity and preferred instead to discuss the symbolic meaning and rationale behind
this ‘rite of passage’, rather than indulging in ethnic and political controversies surrounding the practice (McLean 1980). However, as a result of the western femi- nist movement, FGM has been the subject of intense scholarly studies, both interna- tionally and nationally. Yet the very concept of mutilation denotes that the practice is, prima facie, bad, barbaric, primitive and amounting to torture, discrimination and inhumane treatment. It need not be so.
Authors such as Shell-Duncan (2011) prefer the word ‘cutting’, which she believes is less stigmatising than FGM to describe the practice. Such a descrip- tion has the merit of being neutral and non-ideological and amounts to showing respect to practicing communities. In this book we use the phrases ‘female geni- tal mutilation (FGM) and female genital mutilation/cutting (FGM/C inter- changeably, even though FGM will be most appropriately used to describe the condition as defined by national laws or international treaties. Likewise, we shall described the person who has been subjected to FGM as ‘patient’ (when a person are considered in a clinical context’) and ‘protected person’ or victim’
when the legal context applies.
4.2.2 WHO and UNICEF Classifications
The FGM phenomenon has captured the attention of the World Health Organisation (WHO) as well as the United Nations International Children Fund (UNICEF).
Both international institutions have commissioned studies on the basis of which important classifications have been made of the FGM practice, depending on geo- graphical variation and cultural provenance. The WHO (2006) conducted a global study, which classified all procedures into different typologies. This was completed and modified by UNICEF. The main idea we may get from Tables 4.1 and 4.2 below is that both WHO and UNICEF FGM classifications depend on how elabo- rate or evasive a particular type is, based on how much tissue has been removed
Table 4.1 WHO classification (2014)
Type Description
Type 1:
Clitoridectomy
Partial or total removal of the clitoris (a small sensitive and erectile part of the female genitals) and in rare cases only the prepuce (the fold of skin surrounding the clitoris)
Type 2: Excision Partial or total removal of the clitoris and labia minora with or without removal of the labia majora (the labia are ‘the lips’ that surround the vagina) Type 3:
Infibulation
Narrowing of the vaginal opening through the creation of a covering seal.
The seal is formed by cutting and repositioning the labia minora or majora with or without removal of the clitoris
Type 4: Others All other harmful procedures to the genital for non-medical reasons, for example, pricking, piercing, incision, scraping and cauterising the genital area
from the genitalia. This gives us the idea that any clinical intervention would ulti- mately depend on the form to which health professionals believe their patient has suffered.
Despite the contrast between WHO and UNICEF classifications, there is an agreement that WHO classification, as revised in 2008, should be used and is con- sistently relied upon in the medical scholarship (Creighton and Hodes 2014). The general objection to these classifications, however, is that they are too broad and that if health professionals are to gain an insight into the specific typology, they should examine the genitalia and anatomy of the affected part. This is because a finding on the genitalia observed in some patients may not always be consistent with the offi- cial classifications in Tables 4.1 and 4.2. Moreover, as noted by Poulain (2007), where a patient has experienced childbirth or de-infibulation, the initial procedure (FGM) and child birth or de-infibulation procedures may make difficult to deter- mine the change in the genitalia is due to original FGM or interventions during childbirth or otherwise. Thus, for data collection purpose, the UNICEF classifica- tion is routinely used when dealing with children suspected to have been subjected to FGM.
While there is no clear official guidelines as to how WHO classification might be compared to UNICEF typology, some scholars have introduced some measure of clarity by saying that UNICEF Type 1 corresponds to WHO Type 4, whereas UNICEF Type 2 reflects WHO Type 1 and 2 (Clitoridectomy) with UNICEF Type 3 matching WHO Type 3 (Creighton and Hodes 2014).
Before examining the health risks and consequences posed by FGM, we want to show graphically where those official classifications fit into the anatomy and physiology of the genitalia. For educational and training purposes, we give and then describe graphic representations of the female genitalia Figs. 4.1, 4.2, and 4.3 below.
In Chap. 4, we narrowed down the scope of FGM to being about a classifica- tion under WHO or UNICEF categorizations. From Chaps. 2 and 3, we can see that the numbers of people suffering or at risk of undergoing FGM are growing around the world, despite slight decline in some regions. On balance, this com- plex picture means that prevalence is largely contributing to escalating health complications and an increasing public health burden for governments worldwide. Thus, although there is a dearth of data to quantify the impact of FGM on health outcomes globally, the next section brings together various health consequences reported in several empirical and meta-analytical data to tease out the effects on health of FGM as observed in clinical and non-clinical environments.
Table 4.2 UNICEF classification
(2013) FGM type Description
Type 1 Cut, no flesh removed Type 2 Cut, some flesh removed Type 3 Sewn closed
Type 4 Type not determined/not sure/doesn’t know