Sculptors of Women's Bodies
Bringing Awareness to Female Genital Mutilation Cutting and Improving Obstetric Care for Infibulated Women
Female genital mutilation and cutting (FGM/C) involves the partial or total removal of the female external genitalia for non-therapeutic reasons [1]. The World Health Organization (WHO) estimates that over 200 million girls and women alive today have undergone some form of FGM/C in approximately 30 countries in Africa, the Middle East, and Asia [2]. There are many devastating outcomes and complications that arise from FGM/C which severely decreases an infibulated female’s quality of life. For instance, infibulated girls and women experience urinary problems, vulvar scarring, clitoral pain, and face many obstetric challenges [3,4]. Such experiences also impose negative effects on one’s emotional, sexual, and mental well-being [4].
With an increase in migration of women from FGM/C practicing countries to non-FGM/C practicing countries, such as Canada and the United States, Western medical care practitioners are seeing an increase in patients with FGM/C and FGM/C-related health issues [5]. However, such medical professionals lack clinical practice, cultural context, and knowledge of FGM/C, therefore they are ill-equipped to effectively and appropriately treat women who have undergone FGM/C.
In providing background to the practice and discussing the obstetric challenges many women experience due to their cut genitals, the hope is to bring awareness to the practice of FGM/C and highlight the importance of Western physicians’ cultural understanding and relativity of health issues like FGM/C.
Original illustration by Karly Franz.
Types of FGM/C
FGM/C has been classified into 4 types. Type I involves the partial or total removal of the clitoral glans and or the prepuce and the clitoral hood [2]. Type II involves the partial or total excision of the clitoral glans and the labia minora, with or without excising the labia majora [2]. Type III, also known as infibulation, involves the narrowing of the vaginal opening by creating a covering seal by cutting and repositioning the labia minora or labia majora [2]. Type IV includes all other harmful procedures to the female genitalia for non-medical purposes such as piercing, pricking, scraping, incising, and cauterizing [2].
Cultural and Social Background of FGM/C
Typically, FGM/C is carried out on young girls aged between infancy and 15 years old; however, in some cultures, women are mutilated during their wedding night or their first pregnancy [6,7]. FGM/C is a rite of passage in many cultures, and it is generally performed by elderly women who do not have any medical knowledge [6]. The instruments used for FGM/C include razors, knives, scalpels, scissors, or pieces of broken glass and the practice is usually performed in unsterile environments, thus increasing the risk of infection [6,7]. Although there are efforts implemented in FGM/C practicing regions to eradicate the practice, the dynamics that perpetuate FGM/C have deep societal roots.
The traditional and cultural practices of FGM/C vary between different ethnic groups; however, FGM/C serves the encouragement of the patriarchal family system and is an instrument for birth control [6]. In practicing cultural, FGM/C is performed to ensure virginity and purity before marriage, increase a girl’s or women’s marriageability, enhance sexual pleasure for men, and guarantee moral behaviour and faithfulness of a woman to her husband [6,7]. FGM/C is also associated with cultural ideals of modesty and femininity, which includes the idea that girls are clean, beautiful, and pure after removing body parts that are considered unclean, unfeminine, or male [2,6,7].
FGM/C is largely a social convention and there is a lot of pressure for families to conform to the tradition in order to be accepted by members of their community. The majority of parents from FGM/C practicing regions believe they are not doing this to their daughter, but rather for their daughter [10]. For example, FGM/C is often performed to enhance marriageability as in many societies, marriage and motherhood are a woman’s career. By not circumcising their daughter, parents believe they have done her a disservice as she may be viewed as filthy, ineligible for marriage, and may thus be shunned from their community [10]. Therefore, religious leaders and parents enforce cutting within their community in order to ensure that future generations of girls and women maintain and sustain the tradition and familial social acceptance. This is a significant social issue for women specifically as it largely affects their role in society.
FGM/C is largely a social convention and there is a lot of pressure for families to conform to the tradition in order to be accepted by members of their community.
Obstetric and Gynecological Challenges
Infibulated women can experience a multitude of complications from FGM/C such as urinary issues, vulvar scarring, formation of cysts or neuromas, pain, and infertility [10]. Many women with FGM/C, specifically type III, also experience obstetric challenges such as failed induction of labour, complications with vaginal delivery, and inequitable cesarean deliveries (CDs) when treated by Western medical care practitioners as many physicians have poor knowledge, clinical experience, and cultural context of FGM/C [8,9]. For instance, in Canada and the United States (US), immigrant women’s expectations of vaginal delivery are not well met by obstetric practitioners as physicians have poor experiences when medically caring for women with FGM/C during childbirth [8,9]. Therefore, CDs are unnecessarily and hastily performed on women with FGM/C as physicians do not know how to navigate infibulated anatomy for vaginal delivery or are shocked by a women’s cut vulva [11,12]. Studies also report that CDs should only be performed on women with FGM/C for the same reasons an uncut woman giving birth would need. However, immigrant women with FGM/C in North America have higher rates of CDs compared to women without FGM/C due to Western physician’s lack of understanding of genital cutting and infibulated anatomy [13,14]. The obstetric challenges and inequitable obstetric care provided to immigrant women with FGM/C in Canada and the US suggests that physicians must have a comprehensive cultural, social, and medical understanding of the practice in order to better treat their patients and reduce negative birth experiences for women with FGM/C.
Improving Medical Care Women with FGM/C Through Cultural Competency
Cultural competency is defined as the ability for individuals to establish effective interpersonal relationships with people from different cultures and backgrounds [16]. Cultural competency is paramount when treating women with FGM/C, therefore it is crucial for physicians to understand the traditional beliefs behind this practice instead of being repulsed by its existence [10]. As mentioned previously, some physicians are unfamiliar with FGM/C, therefore they may be shocked or unprepared to see the infibulated scar. Physicians are also reported to improvise medical treatment when caring for women with FGM/C during childbirth given their poor clinical experience [8,9]. This demonstrates extremely poor medical practice as women may experience great distress when medical providers display pity, horror, confusion, or disgust when viewing their genitals. Many infibulated women may enter a physician’s office with their own fears and believe that their physician may unfairly judge them for their cut genitals. Unfortunately, many women have described being left in stirrups while medical students and residents are brought in to view their vulvar scars [10]. Not only does this humiliate the women, but it also demonstrates the insensitivity of Western medicine.
Given such negative experiences, women may avoid seeking medical care to treat complications from FGM/C. Therefore, physicians must incorporate cultural competency and sensitivity when treating women with FGM/C as this will help health providers deliver more effective treatments to their patients. This can be achieved by discussing their patient’s concerns about their cut genitals before the examination, a physician learning and understanding the practice from a cultural and social standpoint before meeting their patients, and being extra sensitive and attentive during the medical history and physical examinations. Clinics can also offer patient’s a female practitioner if preferred and provide patients opportunities for feedback and evaluation to further improve their experiences. Medical schools in Western countries should also teach students about FGM/C to help future physicians feel better prepared to communicate and treat girls and women affected by FGM/C. Not only will such practices and interventions improve FGM/C patient-physician relationships, but women with FGM/C will also feel more accepted, respected, and comfortable when seeking medical care from Western practitioners.
Cultural competency is paramount when treating women with FGM/C, therefore it is crucial for physicians to understand the traditional beliefs behind this practice instead of being repulsed by its existence.
FGM/C is a practice and tradition deeply embedded in the culture and identity of many racial and ethnic groups around the world. Thus, eradication of this practice is highly unlikely. However, improving cultural competency of FGM/C is possible and should be encouraged within the medical field. Given the increase of migration of women from FGM/C practicing countries to non-FGM/C practicing countries, the practice warrants greater depth in knowledge by Western medical practitioners. Therefore, medical professionals must educate themselves to understand the cultural context of this practice in order to provide higher standards of care to their patients. Greater cultural competency in FGM/C care will ensure that women with FGM/C are treated with respect and dignity through empathy, cultural sensitivity, and quality medical care for their vulnerable population.
Sangkavi Kuhan (she/her) is a fourth-year undergraduate student at the University of Toronto double majoring in Health Studies and Music. She is a member of the 2022/2023 Juxtaposition Magazine Editorial Team.
References
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