TWEET CONFERENCE SCRIPT: A Comprehensive approach to ending Medicalization of FGM in Nigeria – 10th January 2019”
In Nigeria, the prevalence of FGM in women aged 15–49 is 24.8%. 20 million women and girls in Nigeria have undergone FGM. This represents 10% of the global total.
Today, our focus will be on “A Comprehensive approach to ending Medicalization of FGM in Nigeria”
For the sake of those hearing FGM for the very first time, we shall have a brief introduction on the issue.
Female genital mutilation (FGM) otherwise known as female genital cutting or female circumcision is defined as “all procedures that involve the partial or total removal of the external female genitalia, or any other injury to the female genital organs for non-medical reasons”.
In other words Female genital mutilation (FGM) is any procedure that causes injury to the female genitals without medical indication.
The World Health Organization (), classifies FGM into four broad types, and subgroups, based on the anatomical extent of the procedure, and they are all practices in Nigeria: …
Type I: partial or total removal of the clitoris and/or the prepuce (Clitoridectomy).
Subgroups of Type I FGM are: type Ia, removal of the clitoral hood or prepuce only; type Ib, removal of the clitoris with the prepuce.
Type II: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
Subgroups of Type II FGM are: type IIa, removal of the labia minora only; type IIb, partial or total removal of the clitoris and labia minora; type IIc, partial or total removal of the clitoris, labia minora and labia majora.
Type III: narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).
Subgroups of Type III FGM are: type IIIa, removal and apposition of the labia minora; type IIIb, removal and apposition of the labia majora.
Reinfibulation is covered under this definition. This is a procedure to recreate an infibulation, for example after childbirth when defibulation is necessary.
Type IV: unclassified – all other harmful procedures to the female genitalia for nonmedical purposes, for example, pricking, piercing, incising, scraping and cauterization.
FGM functions as a self-enforcing social convention or social norm. In societies where it is practiced, it is a socially upheld behavioural rule.
Families and individuals continue to perform FGM because they believe that their community expects them to do so.
Families further expect that if they do not respect the social rule, they will suffer social consequences such as derision, marginalization and loss of status.
While FGM is de facto violent, it is not intended as an act of violence. It is considered to be a necessary step to enable girls to become women and to be accepted, together with the rest of the family, by the social group of which they are part.
Moreover, the removal of or damage to healthy genital tissue interferes with the natural functioning of the body and may cause severe immediate and long-term negative health consequences.
A 2017 research by shows that in Nigeria, FGM is still largely performed by traditional cutters (traditional circumcisers and TBAs), but there is evidence that families, instead of abandoning the practice, are opting for more medicalised forms.
WHO defines FGM medicalisation as ‘situations in which FGM is practiced by any category of health-care provider, whether in a public or a private clinic, at home or elsewhere.
Medicalization of FGM also includes the procedure of re-infibulation at any point in time in a woman’s life’.
Although medicalisation is presumed to reduce risks of complications, it does not eliminate them, and does not change the fact that FGM is a violation of girls’ and women’s rights to life, health, bodily integrity, and freedom from torture and cruel, inhuman or degrading treatment.
Several other frequent assumptions about medicalisation include sharply rising rates of medicalisation, that it does or does not minimise the degree of cutting, and that it does or does not legitimise the practice.
Nigeria Demographic Health Survey (NDHS 2013) reveals that 11.9 percent of girls (ages 0 to 14) and 12.7 percent of women (ages 15 to 49) were “circumcised” by a medical professional.
The NDHS 2013 also reveals that medicalization of FGM in State like Imo State-61%; Delta State-28.9%; Ekiti State-26.2% and Kaduna-22.4%.
Orubuloye et al (2000) noted rapid medicalisation among the Ekiti Yorubas, as health providers (mostly nurses) were increasingly performing FGM.
Orubuloye et al (2000) observed that nurses were practicing a less extensive form (nicking) to minimise complications and limit the amount of attention any complications would draw to their practice.
A study of 250 health workers in southwestern Nigeria found that almost half (48.4%) had been asked to perform FGM (Adekanle et al 2011). It is important to note that medicalisation of FGM in Nigeria is occurring within a health system that is weak and plagued by poor coordination…
The fragmentation of services, insufficient resources including drugs and supplies, inadequate and decaying infrastructure, inequity in resource distribution and access to care, and very poor quality of care (Adeloye et al 2017, Welcome 2011). The Nigerian health system is also ineffectively regulated which contributes to the existence of phenomena such as non-trained or unlicensed individuals providing health services to an unknowing public.
Also trained health providers are violating professional and/or health facility norms by engaging in unethical behavior like the provision of FGM. The performance of FGM by health-care providers, despite the global recognition of FGM as a harmful practice and a violation of human rights, constitutes a break in medical professionalism and ethical responsibility. In Nigeria, it also constitutes a violation of the law.
The involvement of health-care providers in the performance of FGM is likely to create a sense of legitimacy for the practice. It gives the impression that the procedure is good for health, or at least that it is harmless.
Medicalization of FGM can further contribute to institutionalization of the practice, rendering it a routine procedure and even leading to its spread into cultural groups that currently do not practice it.
Furthermore, the medicalization of FGM may lead to some health-care providers developing a professional and financial interest in upholding the practice. Performance of FGM by health-care providers contributes to upholding the practice of FGM. Medicalized FGM is not necessarily safer or less extensive. It also ignores the long-term complications of the practice, including sexual, psychological and obstetrical complications that have been found to be associated with FGM, independently of who performs it.
Also there is no evidence to suggest that medicalization of FGM serves as a first step towards full abandonment.
Why reinﬁbulation should be prevented Reinfibulation recreates, usually several times during a woman’s life, the (removed) tight vaginal introitus of the original infibulation.
This recreates the same problems of gynaecological, sexual and reproductive health, including difficulties associated with childbirth and the need for further surgeries that the original infibulation had created. This consequently repeats and increases the suffering for girls and women.
To end medicalization fo FGM, a comprehensive approach need to be followed.
- Health-care providers should not perform any type of FGM in any setting – neither should they perform reinfibulation after delivery or in any other situation.
- Health-care providers should provide care for girls and women suffering from complications associated with FGM, including special care during childbirth for women who have already undergone FGM.
- Health-care providers should counsel women suffering consequences from FGM, and their families.
- Health-care providers should advise them to seek care for their complications and mental health consequences, advise them against reinfibulation, and counsel them to resist having FGM performed on their daughters or other family members.
- Health-care providers should also act as advocates for the abandonment of the practice in the community at large.
When providing care to migrant women and in cases of limited language skills, health-care providers should have access to cultural interpreters specifically trained on FGM. This will ensure that counselling to women and families is adequate and done with respect for their cultural beliefs.
Nigeria should set priorities and develop specific plans of action according to the country situation, within a consultative process involving all stakeholders.
To end medicalization of FGM, Nigeria should adopt the Four overarching activities listed in the Global strategy to stop health-care providers from performing FGM, which are:…
- Mobilize political will and funding
- Strengthen the understanding and knowledge of health-care providers
- create supporting legislative and regulatory framework
- strengthen monitoring, evaluation and accountability.
(i)Mobilize political will and funding: Political will and funding are necessary to ensure the development and sustained implementation of policies, guidelines, and laws. Necessary actions in this area are to: build strong advocacy support for investment in supporting the abandonment of FGM, engaging political leaders, other leaders, parliamentarians and government ministries. mobilize and coordinate the efforts of key stakeholders to support a national policy against the medicalization of FGM. This includes parliamentarians, healthcare providers, legal experts, human rights groups, government ministries, political leaders and parties, professional organizations, religious and community leaders, including leaders of migrant communities, and other persons of influence
Advocate for sustained and coordinated planning, budgeting and actions for key stakeholders.
Advocate for the establishment of a sustainable, co-coordinated public and private partnership in financing FGM-abandonment programmes.
(ii) Strengthen the understanding and knowledge of health-care providers: A prerequisite for preventing the medicalization of FGM is that all health-care providers should be familiar with: factors surrounding the practice of FGM. Health-care providers should be equipped with the reasons why FGM should not be performed by health-care providers and how to resist requests to do so from parents. Health-care providers should be equipped with how to recognize and manage complications of FGM, including suitable obstetric care; and how to counsel women and families on FGM-related issues.
Guidelines should be in place, including medical, ethical and legal information, such as how to counsel and care for girls and women who have undergone FGM, including counseling against reinfibulation.
Deeply rooted discriminatory norms and practices that underlie FGM, including sexual concerns and eventual religious underpinnings, should be addressed, where relevant, when designing training programmes and developing protocols.
Training should also cover the social conventional nature of the practice to enable health-care providers to appreciate how medicalization will reinforce the social convention and perpetuate the harm.
Training should also cover how they can play a key role in helping practicing communities to abandon the practice and permanently remove the risk of future harm.
Necessary actions in this area are: appropriate national authorities should develop national guidelines for various health-care providers on how to deal with issues related to FGM, including how to care for complications and on how to resist pressure to perform any form of FGM, including reinfibulation.
Training modules on FGM for inclusion in pre- and in-service curricula and training, including refresher courses and updates for all health-care providers, should be developed. This includes nurses, midwives, and medical doctors as well as various health outreach workers.
Training of health-care providers should be integrated at the community level with other community-based activities promoting the abandonment of FGM.
(iii) Create supportive legislative and regulatory frameworks: States should adopt, implement and enforce specific legislation addressing FGM, in order to affirm their commitment to stopping the practice and to ensure women’s and girls’ human rights. Alternatively, existing laws should be enforced in the absence of specific legislation on FGM, such as Child-Right laws, VAPP Law and FGM Laws.
To avoid defiance and the practice going underground, it is important that all legal action takes into account the degree of social acceptance of the practice. A broader initiative that includes direct activities to empower practicing communities to abandon the practice should be considered.
Health-care providers should be informed without delay about human rights and ethical perspectives as well as the harmful consequences of FGM, and that performing FGM, including reinfibulation, would give rise to civil and criminal liability.
Appropriate ethical guidelines on FGM should be incorporated into the training curricula of health-care providers.
The Ministry of Health and professional regulatory bodies should issue a joint policy statement against the medicalization of FGM, and laws and policies and/ or the application of existing laws. Policies should address the role health-care providers play in the elimination of FGM and forbid the performance of any type of FGM, including reinfibulation.
Training on how to deal with medicalization of FGM should also be provided to juridical staff and law-enforcement and security personnel.
Professional organizations should adopt and disseminate clear standards condemning the practice of any type of FGM and issue firm guidelines for their members not to perform FGM, and not to accept or support its practice.
Licensed health-care practitioners must be subject to the maximum available criminal penalties that apply to anyone performing FGM. Offending practitioners may be suspended or their licences withdrawn if they perform FGM.
Women and girls should be educated about their human rights and be empowered to access legal remedies specified by law to prevent FGM.
Women and girls should have the right to bring civil action suits to seek compensation from practitioners, or to protect themselves from undergoing FGM. Wherever possible, health-care providers should assist by providing evidence supporting the claims of the girl or woman who has undergone FGM.
(iv) Strengthen monitoring, evaluation and accountability: Monitoring and evaluation are essential for improving health-care providers’ approaches to FGM and for refining plans to promote abandonment of the practice. Government participation is critical for gathering data and broadening national monitoring mechanisms.
Necessary actions in this area are to:
(1) monitor health-sector training and implement the lessons learned.
(2) develop mechanisms to increase accountability at facility and district levels.
(3) routinely collect data on FGM (e.g. antenatal records).
(4) monitor providers of FGM, including legislative measures taken against them.
(5) Nigeria should integrate FGM, including reinfibulation, into existing monitoring and evaluation systems in the country (sexual and reproductive health, HIV/AIDS, gender-based violence, demographic and health surveys data collection, etc)
(6) report to UN human rights treaty bodies and other international and regional human rights bodies; and institutionalize feedback mechanisms to the communities.
In conclusion, all health-care providers take an oath of practice in line with the Hippocratic Oath and other relevant statements of ensuring no harm against any patient.
Therefore, Health-care providers should know and respect the health and human rights aspects of FGM and refrain from supporting or performing any form of the practice. medicalization of all forms of FGM violates human right, ethical principle of justice, beneficence and non maleficience and the medical code of ethics.
To learn more about the Social Media Campaign to end FGM, please visit endcuttinggirls.org and follow our social media handles on Facebook, Twitter, Instagram and YouTube, using
References: Suggested Citation: Obianwu, O., Adetunji A., Dirisu O., January 2018. “Understanding medicalisation of Female Genital Mutilation/Cutting (FGM/C): a qualitative study of parents and health workers in Nigeria.” Evidence to End FGM/C: Research to Help Women Thrive. New York: Population Council.
References: – Global Strategy to end medicalisation FGM and Joint UNFPA-UNICEF Programme on Eliminating FGM: Accelerating Change.
At this point, I will end the presentation to give room for questions and contributions from participants. Thank you all for reading our tweets