'Help! Parents are secretly cutting the genitals of their daughters'

Female genital mutilation, ranging from the cutting off of the clitoris to the removal of the entire  genitalia carried out from the youngest babies to teenagers has become a serious global public health and human rights issue.

The World Health Organisation (WHO) declared that over 125 million women have been mutilated in 29 countries in Africa and Middle East, while condemning the practice as a 'violation of the human rights of women'.

United Nations Secretary General, Ban ki-Moon, recently, in Nairobi, Kenya, launched a global campaign to end the deadly practice saying, 'the mutilation of girls and women must stop in this generation, our generation'

In this interview with Dr. Adedoyin Ogunyemi, a public health expert who leads an advocacy group in Nigeria committed to stopping Female Genital Mutilation (FGM), talks about it, the extent the practice is ravaging our country and how to tackle the problem and restore the dignity and respect of our girl children. She is of the Royal Hospital, Ojodu, Lagos.

What is female genital mutilation (FGM)? Female genitalmutilation is actually female circumcision which is a harmful practice carried out in most African countries and the Middle East - Yemen was recently included.

The practice involves total or partial removal of some or all the female external genitalia or genital reproductive organs, for cultural, non-medical reasons, causing injury to the female organs. In the circumcision, the glands and clitoris, the vaginal tips are cut off. It's no longer circumcision, but mutilated. We see the practice as violation of human rights of women. They ought be free from discrimination, coercion. It is violence considering the injury, both physical and psychological, beyond public health issue.

Explain the types of FGM?
There are various types of FGM. Type 1 is the removal or excision (cutting off) of the prepuce, the glands and part of or all of the clitoris - sensitive part of the vagina, the outer lips. Type 2, removal of the whole clitoris and the partial or total excision of the labia minora.

Type 3, cutting off or excision of the external genitalia or labia majora, that is removing all the clitoris and the vaginal tips, stitching, or narrowing of the vaginal openings, leaving only a small opening for urine and menstruation to pass through. Type 4, piercing or incision of the clitoris or the labia stretching of the clitoris and or the labia or burning the clitoris and surrounding tissues and the vagina opening. Then, there is the introduction of corrosive substance or herbs into the vagina which can cause bleeding and narrowing and tightening of the vagina.

Are there health consequences involved in these types of mutilations? Can you specify the consequences?

Yes, there are short and long term health consequences. The short term ones include severe pains (no anaesthetic or pain killing drugs administered), bleeding, anaemia, low blood level due to bleeding, infection like tetanus, hepatitis B, HIV, AIDS, etc. There will be urinary retention because urine stays back. Haemorrhage or severe bleeding during circumcision could lead to even death.

The long term health consequences include abcess, painful cyst, scars, keloid, painful sexual intercourse, difficult pregnancy and child birth, obstructed labour, narrow vagina, tightening makes labour very difficult and therefore resort to caesarian section, retention of menstrual fluid as blood can't flow, eclampsia, hypertension, unsafe abortion, higher post partum.

Infertility could occur and the women may not know - because there is no where for the menstruation to come out. There can be 'still births' as babies can die, before the time of delivery.

There are also psychological consequences which include low self-esteem, poor concentration in school while bleeding can cause death.

Can we know, from your findings, the reasons for female circumcision?

The reasons are mostly socio - cultural. No religious undertone, but spiritual purity may be adduced for the practice. You also have the need to preserve virginity, cultural identity, sense of pride of the coming of age, passage from being a girl to womanhood, to prevent promiscuity, sexual escapades by teenage girls. But it may rebound as fear of sexual intercourse could lead to frigidity and unwillingness to respond to lovemaking. Reasons vary according to different ethnic beliefs.

What is the prevalence rate of FGM in Nigeria?
About 30% of our women have been cut. It should be zero. I can recall that some years ago when the late First Lady, Mrs. Stella Obasanjo attended a women's conference held in a foreign country, she advocated zero tolerance for FGM and a day to be set aside by the UN to mark it around the world. I think it was 6th February that was fixed and being observed worldwide.

FGM is both a public health issue and also human rights. It must be dealt with. It is harmful. Nigeria has the highest maternal mortality rate in the world - 576 per 100,000 which is 13% of the global maternal mortality rate. If female circumcision is adequately tackled,it can reduce maternal mortality rate in this country. Public health issues should be dealt with beyond building of hospitals and magnificent medical facilities.

Female circumcision is carried out on babies from age of infancy, 2, 5 years to teenagers, particularly in babies to reduce the horror of the pains. Currently, some states in Nigeria such as Ekiti, Abia, Ondo, Lagos, Bayelsa, Rivers, Ogun, Osun, Cross River and Edo have laws prohibiting female genital cutting. Many others are yet to enact laws prohibiting FMG, allowing it without noise done to kids and babies because it heals faster on babies, with less trauma. There is no singular federal legislation against FGM at the moment. The problem is still there. Provision of clean water for the public will help combat many diseases.

You lead an advocacy group - Healthmark Consult, a public health organisation. How are you tackling FGM? There should be more media campaign and enlightenment on this harmful practice. Media involvement is lacking. Many people are not aware of the health consequences of FGM.

Girl, children or women should not be circumcised at all in the first place, unlike boys who need to cut off the prepuce or tissue on the outer tip of the penis. It must be removed for boys - for medical reason. More information and education on harmful effects of female circumcision on health of the girl or woman is needed across thecountry. It is not over yet.

For girls, there are other alternatives to FGM. Chastity rings, bangles can be worn to signify their virginity and readiness for marriage. Government must do more to reduce poverty, inequality; ensure gender balancing in education; discourage early marriage for girls; enhance access to education and health services, female empowerment. We need a mechanism to ensure community  dialogue involving men, women, boys, girls, old and young.

We need to ban early marriages, encourage people to speak out-men and boys. Why should a girl be cut! Unfortunately, FGM is about women against women. We should speak to female circumcisers who do this work, provide alternatives like offering them loans to trade or acquire vocational skills. Let's try focused group discussion capable of having snowballing effect - one to another. Medicalisation of FGM may seem proper, but what is bad is bad. Female circumcisers are found in several villages across the country. These are women themselves engaged to cut off female sex organs.

Why are we not getting experts' statistics, figures on FGM and survivors or victims to speak? Many things are expected to be done, but not done. It used to be 41% but dropped to 19%. It will keep falling until people speak out. Speaking out can get FGM to zero level.

Systematic random sampling may be difficult to get, even what we get is a tip of the ice berg. It could be more. If we have improved social justice, people can speak up and be heard. Legislation had been slow and slack without lobby. More of peer activities, peer education, multi-pronged approach are required. If a public health issue like this is not problemised, we cannot get it done. Survivors and victims of FGM can't speak for fear of stigmatisation.

According to the Nigerian Demographic Health Survey, NDHS, done every five years, one in four women, aged between 15 - 49 years has been circumcised. In the 2013 survey, Osun State has the highest with 77%, Ebonyi 74%, Ekiti 72%, while Katsina had lowest 0.1%.

On the prevalence rate, South-West is 47.5%, South-East 49%, South-South 25.8%, North-West 20.7%, North-Central 9.9%, North-East 2.9%. Among ethnic groups, Yoruba have the highest with 55%, Igbo 45%, Hausa 19%, Ijaw 13% and Fulani 13%.FGM is highest among daughters of circumcised women. Elite women with good jobs, professionals in various fields of endeavour are not left out, but female circumcision is done in secret, no noise. Many parents are cutting the  genitals of their daughters secretly especially in the rural areas which can be stopped, not only by legislation but also through persuasion, community enlightenment, family and peer discussion. The campaign against FGM should go down to the grassroots where this deadly practice is still rampant. Vanguard