The Legislation and Solution for FGM in the United States and Africa

Background

The World Health Organization (WHO) has classified female genital mutilation into several categories. The WHO defines mutilation or cutting as the “partial or total removal of the external female genitalia” for non-medical reasons. While most countries and global organizations, such as the WHO, consider these procedures to be a violation of human rights because of discriminatory purposes as well as the health issues that this procedure can cause.

The WHO has classified four specific types of FGM: Type I, II, III, and IV which are progressively more invasive and destructive. Type I is clitoridectomy which is the removal of the clitoris. Type II is an excision, which is the mutilation or complete removal of the clitoris and the labia minora but without removing or damaging the labia majora. Type III is infibulation, a process of narrowing the vaginal opening by cutting and reforming the labia and may include the removal of the clitoris. Type IV is the most invasive and harmful and includes any mutilation for non-medical reasons, including cutting, scraping, burning or piercing. To perform the procedure, midwives often use tools such as razors, knives, scissors, scalpels, a piece of glass or even a thorn may be used in the process and females may or may not have access to general anesthetics and post-procedure care (WHO). It is because of this that the procedure is so dangerous; infection is difficult to care for and treat, especially if it occurs in a location that lacks medical care.

The health risks involved in any level of FGM include short term consequences such as shock, uncontrolled bleeding, infection, pain, and psychological issues. In the long term risks, there are also the strong possibilities of recurring infections and irritation, infertility, childbirth complications and the need for continued treatment and surgeries (WHO 2012). Research is also showing that women are left permanently psychologically impacted.

Female genital mutilation (FGM) and cutting is a cultural ritual that has been practiced for more than 5,000 years according to the World Health Organization. There are five reasons that FGM procedures are carried out: psychosexual, cultural, aesthetic, religious and factors of socio-economic reasons. Since the scarring resulting from the mutilation reduces the pleasure women feel during sex it is believed to control women’s sexual urges and ensure virginity. As a cultural ritual, the procedure is seen as being a rite of passage into adulthood and is also believed to improve fertility and protect the baby during birth. In some cultures, the female genitalia are considered disgusting and should be removed to ensure men will find the female appealing. While no specific religious group sanctions FGM, there are some groups who use Islam or Christian teachings to justify the mutilation but few religious leaders outwardly support it (United Nations Population Fund (UNFPA.org)). One of the most complex reasons for FGM is the socio-economic necessity of FGM because without the procedure the women will not be eligible for marriage in their culture. In many of the societies that FGM is practiced, the social structure is patriarchy so women must marry for financial and societal support.

This is also a trend that appears to be continuing at a fairly consistent rate. UNFPA estimates that three million girls are living in societies that practice FGM and are, therefore, at risk. This would add to the over 100 to 140 million girls and women who have already undergone the procedure. Female genital mutilation is performed at different ages in different cultures. In some cultural groups, the procedure is completed on a newborn while others wait until childhood, some even wait until marriage, during pregnancy or after the birth of their first child. UNFPA studies found that most of the circumcisions occurred when girls were between 7-10 years old, before puberty and marriage eligibility.

Finding legal solutions to cultural practices is difficult because communities may be following a tradition that has been passed down for generations. FGM is one of these practices, for some, not following the ritual means forcing their daughters to be ineligible for marriage. This is one of the problems with approaching FGM from a legislative perspective, in the eyes of the people who practice this, it is more of a social issue than a legal one (AHA.org). Another issue is that laws may be passed at the government level but lack enforcement and midwives are may not be registered with the state in African countries. Without knowing who could be potentially performing the surgical process and with little enforcement from local police, it is not likely that the states will see change.

Legislation

In the Congressional Bill H.R. 1860, the Criminal Code Modernization and Simplification Act of 2013, Section 115 focuses on Transportation for Purposes of Female Genital Mutilation. Since non-consenting mutilation is already illegal in the United States, this bill deals specifically with transporting girls to foreign countries for the purpose of “circumcises, excises, or infibulates the whole or any part of the labia majora or labia minors or clitoris” of a person under the age of 18 (1860: 115). The exceptions of this law are if the procedure is deemed medically necessary and must be completed by an individual trained in the surgery.

On the state level, New Jersey has recently passed legislation first introduced in 2012 by Senator Loretta Weinberg, it passed a Senate vote unanimously and Bill S1171 signed into law as of January 17, 2014. The law is highly similar to the federal law, protecting girls under 18 from circumcision but also included additional information regarding the possible defense of the act. The bill states that “it shall not be a defense to a prosecution” if the procedure is completed because of customs or rituals or if the guardian consents to the procedure. Charges for breaking this law are of a third-degree and carry short jail sentences or a fine not to exceed $3000.

International legislation has also been developing to reduce the cases and acceptance of FGM in Africa. Some countries in Africa have banned the practice completely, including Benin, Burkina Faso, Central African Republic, Chad, Cote d’Ivoire, Djibouti, Egypt, Ghana, Guinea, Kenya, Niger, multiple states in Nigeria, Senegal, Tanzania and Togo. Sudan has banned only the most extreme Type 4 level of FGM. The punishment for carrying out FGM in Africa can range widely; from a financial penalty to time in prison.

My Opinion

While federal and state legislation has prohibited the mutilation of females under the age of 18, as well as the transport of females to other countries to complete the surgery, it can be a difficult crime to track because of the inclusion of the act into people’s cultural identity. The procedure is done out of culture and custom and the parents of the girl want the surgery for their daughter so that she might better integrate into their cultural group. Since the act is perpetrated by mothers and fathers, this shows that they do not recognize it as a crime and that by not ensuring their daughters are circumcised, they are ensuring that the girls will not fit in.

I was surprised at the treatment of the crime as being a third-degree crime by New Jersey legislation when child abuse allegations would bring a much heavier sentence on parents. Considering that female genital mutilation is a highly painful and risky procedure and that the implications are life-long, the law may be better placed under child protections and proceed with a heavier penalty. For a father, he may see a fine as a worthy penalty if he is able to carry out his traditions by submitting his daughter for surgery.

For adult women, they can, of course, consent to the procedure as they would any non-necessary surgery. Laws protect individuals who self-mutilate or seek procedures such as scarification, sub-dermal implants, and tattooing so a woman who belongs to the culture may submit herself to the ritual if she decided to. Since it is cultural pressure that ensures the procedure continues the best line of defense is to educate the parents about the complications involved in female circumcision as well as the other problems it may cause. Since many of the mothers, sisters, daughters, and friends may have had the procedure themselves, it will be difficult to convince parents to not follow the status quo presented to them by their culture. If parents are knowledgeable about the danger and unnecessary nature of the procedure, especially the possibility of infertility, they may decide to not carry out the mutilation. Since this approach has worked for other social issues – the treatment of women, children, disabled people, etc. - it may work for female circumcision.

Since the laws are only able to intervene to a certain extent, the best protection federal and state laws can offer are for children under the age of 18. Even if a family abides by the law and does not illegally circumcise their female children, there are probably pressures on young women who face the struggle of marrying outside of their culture to men who do not expect their wives to be circumcised. This is where the social change will be the most beneficial, once the laws no longer shield the women from the procedure, there is nothing the legal system can do.

I think it may be most beneficial to approach this issue as some of the non-profit organizations such as the AHA.org Foundation and UNFPA. They support and encourage stronger legislation at the federal and state level, but also work to change the social expectations in cultural groups that traditionally practice female circumcision. As with many laws that deter ritual practices, the families will still continue the traditions in secret, regardless of how many laws are put in place. By educating the women and girls of African society about the non-necessity of the surgery, they may be able to help push the change. It will be a struggle to fight against hundreds of years of social expectations, but it is in the best interest of the females of their society and change is possible.

I also understand that cultural rituals are sensitive topics with patients who seek care. There is a wide variety of belief systems and while I do not wish to push my cultural values onto my patients, procedures like FGM have no medical value and are often the cause of continued discomfort and pain for the women. While I might sympathize with a patient who was part of a culture that was different than mine, I don’t believe that rituals should be continued just for the sake of how it has always been. The procedure is dangerous and painful and there is no gain from it.

As a nurse, the only time it is likely that I will have contact with a female who has undergone the procedure is if she arrives at the clinic needing medical treatment because of the complications of the mutilation. This is difficult because it is only a tertiary action, the act has already taken place and the damage cannot be undone without significant attempts at reconstructive surgery. As with AIDS awareness and so many other health concerns, I believe education and knowledge can stop this practice.

Expert Opinion/Evidence-Based Practice

In the past three decades, the discussion of the purpose and impact of Female Genital Mutilation has increased because of social awareness and the discussion of the topic in medical and social literature. Researchers offer insight and suggestions about ways to deter parents from going through the procedure.

Kaplan, Hechavarria, Bernal, and Bonhoure (2013) studied the reasons why FGM has been a continued practice in the Gambia and found a correlation with attitudes relating to domestic and sexual violence. In a 2010 survey, they found that 74.5% of the women they interviewed believed that husbands were “justified to beat their wives or partners for many reasons, including refusing to have sex, going our without telling them, or burning the food.” Kaplan, et al. study showed the connection between the attitudes of the treatment of women in the Gambia with the acceptance of the practice of FGM. Since, in the Gambia, an estimated 76.3% of girls and women have been submitted to this custom, the researchers found that these two attitudes often appeared in tandem; those women who agreed that their husband should be allowed to abuse them also held the belief that FGM should be practiced. Their research concluded with suggestions of encouraging social change by educating pregnant women about health risks while pregnant while also discouraging parents from performing FGM on their daughters.

One way to approach the subject on a social scale is suggested by Pereda, Arch and Perez-Gonzales (2012) who in, “A Case Study Perspective on Psychological Outcomes After Female Genital Mutilation” discussed the impact of FGM with women who had undergone the procedure. While the women showed high levels of self-esteem, they expressed issues with their sexual relationships. The researchers quote a 2003 Herieka and Dhar study that expresses that men “need to be included and involved in educational programmes” since most of the men they surveyed preferred a wife who was unmutilated. Pereda, Arch, and Perez-Gonzales expressed a similar suggestion, saying that the women’s sexual partners did not express a specific desire for a circumcised female.

For legislation aimed specifically at protecting children, research shows that prenatal, birth and aftercare of pregnant women is an excellent time to intervene on FGM practices. Jaeger, Caflisch, and Hohlfeld (2009) examined pediatric health care providers as being interventionists to keep parents from seeking FGM on their children. They recommended discussing the decision early with both the mother and the father and while the health care providers should be sensitive to cultural practices that nurses and doctors “should also stress the parents’ responsibility in taking a health risk for their daughters.” The researchers argue that parents generally will listen to reason but may need support against their community’s cultural pressure. They also outline conversation points for a discussion with the parents, including listening to the family members’ opinions, discussing their concerns for and against FGM and having resources available for families. Their research found that once the discussion was started with family members they were surprisingly receptive and concerned with the complications.

From a more social convincing aspect, Utz-Billing and Kentenich (2008) make a suggestion of approaching the topic of FGM from a different perspective. Their paper encouraged the leaders of religious groups to criminalize FGM, including creating a fatwa against the practice. They cite that many families that continue the practice of FGM belong to the beliefs of Islam, that a religious legal approach would discourage FGM. They acknowledge that it would be a difficult and lengthy process to reach out to head religious leaders but that leaders who work on a small community level can discourage parents from circumcising their daughters. Sensitivity to the practices of the past are important, they add because the procedure has been used for many years.

Examining FGM and treatment from a nursing standpoint, Terry and Harris (2013) also discuss the importance of caring for circumcised females with compassion. They discuss research that suggests that women with FGM may react poorly to vaginal examinations and that “nurses require the skills to provide patients with emotional support” due to a PTSD-like response. They also acknowledge how nurses can best support their circumcised female patients and encourage them to seek health-care when necessary. Most importantly, however, Terry and Harris present the idea that through personal connections, respect and understanding a nurse can be an advocate against FGM by empowering their patients.

Conclusion/Implications for Nursing

As part of nursing practice, understanding differing cultural values and beliefs is essential to helping patients in their medical decision making. Some religions encourage specific nutritional habits; prohibit blood transfusions or even lifesaving medical procedures. While each nurse approaches these situations with his or her own opinions and background regarding these issues, it is ultimately important that laws (either by contacting law enforcement if abuse or mutilation has occurred) are upheld, especially in situations that are for the protection of the patient.

In the case of female genital mutilation, it is a focus on protecting females under the age of 18 that nurses can help with and focus on caring for circumcised women who voluntarily opt for the procedure. While a nurse may not personally agree with the cultural practice, a patient who needs help should receive it and children should be protected under the laws that were created to shield them from harm. In the case of a nurse who travels to an area where FGM is legal, focusing on the patient and her care is of utmost importance. Research mentioned in an article by Terry and Harris (2013) cited related research by Whitehorn et al (2002) that women who have been subjected to FGM may avoid medical treatment due to feelings of judgment. Similarly, Norman et al’s (2009) study stated in the Terry and Harris article that found that women who were mutilated or surgically altered were the victims of poor practice, with “healthcare professionals […] reacting with shock or gathering other staff to look at the ‘unusual’ woman” (quoted in Terry & Harris 2013). An individual who feels like she is treated differently because of a culturally (in her culture) accepted practice may avoid care. While the results of FGM may appear disturbing and out of the norm, it should be approached with compassion and acceptance by nurses since they are so often the strongest link between an individual and her health care.

If working in an area where there are migrants or while working in a country that practices FGM, it is also important for a nurse to act as an advocate for the safety and health of their patients. Having an open conversation with others, as well as opening one’s own mind to the opinions and beliefs of others, is the first step to understanding a patient. While a nurse does not have to agree with a patient, health care staff can make positive changes by educating families about the dangers and issues that FGM causes. Small successes are likely to be more effective, gaining the trust of the family is pivotal since families may be hesitant to discuss their practices with someone outside of their own cultural group. Providing evidence and logic helps families see that it is not a cultural change that the nurse is pressing for, but a medical one.

Stronger legislation that improves women’s rights in developing countries is one of the best ways to get women involved in their health lives. However, in countries that oppress and allow abuse against women, it can be difficult for the parents of a daughter who are against FGM to stand up. Social and cultural pressures make parents feel as if they are doing their daughter a disservice if they do not follow through with the procedure and they may feel they are ruining her chance for a happy life. Nurses have a unique opportunity to connect with patients; both parents who are deciding on the procedure and with women who may have already undergone it. With the parents of the child, the nurse can open the line of conversation and reach out to them, educate them on the hazards and illegality of FGM in the country they are residing in. The nurse can help connect with resources and people who have similar backgrounds who may be able to help support the family. And, if necessary, after the child is born, the nurse may also watch for signs of illegal female genital mutilation pertaining to the legislation in her area. At this point, reporting harm of the child may be in the best interest of the girl and ensure that the practice is not condoned. In closing, female genital mutilation is an issue that has many different perspectives and beliefs intertwined into a single procedure; however, a surgery that only hurts and does not heal goes against the tenants of medicine and encourages a dangerous act to continue.

References

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