Female Genital Mutilation (FGM) is defined, by the World Health Organization (WHO), as “all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for nonmedical reasons”. The term FGM is preferred by WHO and United Nations in order to convey the irreparable physical and psychological damage done to girls and women.

In 1997, World Health Organization (WHO) classified FGM into four types, namely, Type I (Clitoridectomy); Type II (Excision); Type III (Infibulation); and Type IV (Unclassified).  These types, which were further subdivided in 2008 by WHO, are all practiced in Nigeria.  The four Types of FGM and their subtypes are described below;

FGM Type I: partial or total removal of the clitoris and/or the prepuce (Clitoridectomy).

Subdivisions of FGM Type I are: FGM Type Ia, removal of the clitoral hood or prepuce only and FGM Type Ib, removal of the clitoris with the prepuce.

FGM Type II: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).

Subdivisions of FGM Type II are:  IIa, removal of the labia minora only; IIb, partial or total removal of the clitoris and labia minora; and IIc, partial or total removal of the clitoris, labia minora and labia majora.

FGM 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).

Subdivisions of FGM Type III are: FGM Type IIIa, removal and apposition of the labia minora; and FGM 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 non-medical purposes.  It includes:

• Piercing or incision of clitoris and/or labia.
• Cauterisation by burning of clitoris and surrounding tissues;
• Scraping (angurya cuts) of the vaginal orifice or Cutting (gishiri cuts) of the vagina;
• Introduction of corrosive substances into the vagina to cause bleeding or Herbs into the vagina with the aim of tightening or narrowing the vagina.

FGM Type IV also includes the practice of “massaging” or applying petroleum jelly, herbal concoctions or hot water to the clitoris to desensitize it or pushing it back into the body, which is common in many parts of Nigeria, especially Imo State.

It is estimated that over 200 million girls and women worldwide are living with or at risk of suffering the associated negative health consequences of FGM  

Every year 3 million girls and women are at risk of FGM and are therefore exposed to the potential negative health consequences of this harmful practice.  

The procedure of FGM is painful and traumatic, and is often performed under unsterile conditions by a traditional practitioner who has little knowledge of female anatomy or how to manage possible adverse events.  

FGM has no known health benefits. Moreover, the removal of or damage to healthy genital tissue interferes with the natural functioning of the body and may cause immediate and long-term health consequences, which are listed in 11a and b.  

The “Immediate & Short term complications” of FGM are 1) severe pain and injury to tissues; 2) haemorrhage (bleeding); 3) haemorrhagic shock; 4) infection and septicaemia; 5) genital tissue swelling; 6) acute urine retention; and 7) fracture of bones.

The “long-term complications of FGM” are 1) chronic vulvar pain; 2) clitoral neuroma; 3) reproductive tract infections; 4) menstrual problems; 5) urinary tract infections; 6) painful or difficult urination; 7) epidermal inclusion cysts; and 8) keloids.  

In 2006, WHO study group analysed the obstetric risks associated with FGM and concluded that women living with FGM are significantly more likely than those who have not had FGM to have adverse obstetric outcomes such as 1) Caesarean section; 2) Postpartum haemorrhage (Postpartum blood loss of 500 ml or more); 3) Episiotomy; 4) Prolonged labour); 5) Obstetric tears/lacerations; 6) Instrumental delivery; 7) Difficult labour/dystocia; 8) Extended maternal hospital stay; 9) Stillbirth and early neonatal death; and 10) Infant resuscitation at delivery.

Given that some types of FGM involve the removal of sexually sensitive structures, including the clitoral glans and part of the labia minora, some women may experience the following 1) Dyspareunia (pain during sexual intercourse); 2) Decreased sexual satisfaction; 3) Reduced sexual desire and arousal; 4) Decreased lubrication during sexual intercourse; 5) and Reduced frequency of orgasm or anorgasmia. 

For many girls and women, undergoing FGM can be a traumatic experience that may leave a lasting psychological mark and cause a number of mental health problems, which include 1) Post-traumatic stress disorder (PTSD); 2) Anxiety disorders; and 3) Depression.

The practice of FGM is prevalent in 30 countries in Africa and in a few countries in Asia and the Middle East, but also present across the globe due to international migration  

FGM is practiced for a variety of sociocultural reasons, varying from one region and ethnic group to another. The primary reason is that it is part of the history and cultural tradition of the community.

In many cultures, FGM constitutes a rite of passage to adulthood and is also performed in order to confer a sense of ethnic and gender identity within the community. In many contexts, social acceptance is a primary reason for continuing the practice.

Other reasons for practicing FGM include safeguarding virginity before marriage, promoting marriageability (i.e. increasing a girl’s chances of finding a husband), ensuring fidelity after marriage, preventing rape, providing a source of income for circumcisers, as well as aesthetic reasons (cleanliness and beauty).

Some communities believe that FGM is a religious requirement, although it is not mentioned in major religious texts such as the Koran or the Bible.

FGM practice is deeply rooted in a strong cultural/social framework. It is endorsed by the practicing community & supported by loving parents who believe that undergoing FGM is in the best interest of their daughter.  

The beliefs sustaining the practice of FGM vary greatly from one community to another, although there are many common themes such as ending promiscuity or the maintaining culture tradition of the community.  

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.

While FGM is de facto violent, although 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.   

Despite its cultural importance, we need to acknowledge the fact that FGM is a harmful traditional practice that violates the rights or girls and women.  These include 1) Principles of equality and non-discrimination on the basis of sex; 2) Right to life (when the procedure results in death); 3) Right to freedom from torture or cruel, inhuman or degrading treatment or punishment; and 4) Rights of the child.  Therefore, FGM has to be eliminated.  

When FGM is conducted by healthcare providers this is also known as the “medicalization of FGM”; The medicalization of FGM refers to “situations in which the procedure (including re-infibulation) is practised by any category of health-care provider, whether in a public or a private clinic, at home or elsewhere, at any point in time in a woman’s life”.

Healthcare providers who agree to perform FGM are violating the fundamental medical ethical principle or duty of non-maleficence (“do no harm”) and the fundamental principle of providing the highest quality health care possible. 

FGM remains widespread in Nigeria with regional and ethnic variations in prevalence. 

According to the Multiple Indicator Cluster Survey (MICS 2016 -2017), 18.4% of women aged 15-49 years had undergone FGM, a decrease from 27% in 2011.  The decrease was also observed in the five states where the UNFPA-UNICEF Joint Programme on FGM Elimination (UNJP) is working, namely, Ebonyi: 62.3 % to 43.2%; Ekiti: 66.2% to 62.6%; Imo: 58.4% to 51.6%; Osun: 73.4% to 67.8 %; and Oyo: 71% to 55%).

According to the MICS (2016-2017), the FGM prevalence among daughters aged 0-14 years increased from 19.2% (in 2011) to 25.3% (in 2016-2017).  In the five UNJP intervention states, FGM prevalence decreased in three States, namely, Ebonyi (6.4% to 5.2%), Imo (33.4% to 22.2%), and Oyo states (32.9% to 29.6%). While, a slight increase was seen in Ekiti (40.3% to 41.7%) and Osun (33.4 to 34.6%). 

According to the MICS (2016-2017), 21.6% of women surveyed were in support of the continuation of FGM, a very slight decrease from 21.8% in 2011.  In the five UNJP intervention states a decrease was observed in Ebonyi (11.8% to 3.8%) and Ekiti (50.2% to 31.4%); while an increase was seen in Imo (27.8% to 29.6%); Oyo: (21.2% to 30.3%); Osun: (34.8% to 38.5%).

For more information about FGM you can visit http://www.who.int and www.endcuttinggirls.org  or watch https://www.youtube.com/watch?v=f0-dYD9cYKo&t=80s

Now let us talk about “Ending FGM through provision and accessibility of social and legal services.”  

FGM is a form of extreme harm against women and girls and leads to severe short and long term physical and psychological consequences and may require access to quality services to address their heath, legal and social needs.  .

FGM may lead to psychological and mental health problems because it is an extremely traumatic experience for girls and women, which stays with them for the rest of their lives. In some cases these FGM survivors may not have spoken about their experience for many years, and while receiving psychological counselling many have reported feelings of betrayal by parents, incompleteness, regret and anger.

Now there is increasing awareness of the severe psychological consequences of FGM for girls and women, which can become evident in mental health problems. The results from research in practicing African communities show that women who have had FGM have the same levels of Post-Traumatic Stress Disorder (PTSD) as adults who have been subjected to early childhood abuse, and that the majority of the women (80%) suffer from affective (mood) or anxiety disorders.

The fact that FGM is ‘culturally embedded’ in a girl’s or woman’s community does not protect her against the development of PTSD and other psychiatric disorders. Therefore, there is a need to ensure that mental health support is made available to assist girls and women who have undergone FGM, as well as treatment for any physical symptoms or complications.

It is therefore important to ensure that that the provision of these services, especially social and legal services are integral parts of the campaign to end FGM in Nigeria.  However, since no single agency or statutory body can meet the multiple needs of someone affected by FGM, a multi-agency response is required.

In Nigeria, some of the main social services required by women and girls living with FGM, or at risk of FGM, include referral to social services for psychosocial counseling, counseling, and shelter.  The provision of these services are the responsibilities of the Ministry of Health (MOH), Ministry of Women Affairs and Social Development (MWASD), and other related agencies.  

In Nigeria, some of the main social services required by women and girls living with FGM, or at risk of FGM, include main legal services include judicial counseling and assistance.  These The provision of these services are the responsibilities of Ministry of Justice, law enforcement agencies (Nigeria Police Force, Nigeria Security and Civil Defence Corps), the judiciary and other related agencies.  

In Nigeria, the legal and policy framework has created a conducive environment at national level and state levels to support the campaign to end FGM in Nigeria, as can be show as follows

• The Constitution of the Federal Republic of Nigeria (1999) does not specifically refer to violence against women and girls, harmful traditional practices or FGM; however, Articles 15(2) and 17(2) prohibit discrimination and set out equality of rights respectively, and Article 34(1) provides that every individual is entitled to respect for the dignity of their person and, accordingly, no one ‘shall be subject to torture, or to inhuman or degrading treatment.’

• Although the Child Rights Act (CRA-2003) does not specifically refer to FGM, section 11(B) states that “No child shall be subjected to any form of torture, inhuman or degrading treatment”. .  The CRA 2013, as a federal law, is only effective in the Federal Capital Territory of Abuja, and, as such, the remaining states must pass mirroring legislation to prohibit FGM across the country.  Currently, 24 States of Nigeria have passed their Child Rights Laws, and in some cases the prohibition of FGM is clearly stated.

• The Violence Against Persons (Prohibition) Act, 2015 (the VAPP Act), aims to eliminate gender-based violence in private and public life by criminalizing and setting out the punishment for acts including rape (but not spousal rape), incest, domestic violence, stalking, harmful traditional practices and FGM.  The VAPP Act 2015 states that ”a person who performs female circumcision or genital mutilation or engages another to carry out such, commits an offence punishable by 4 years imprisonment or to a fine of N200,000 or both.  The VAPP Act, as a federal law, is only effective in the Federal Capital Territory of Abuja, and, as such, the remaining states must pass mirroring legislation to prohibit FGM across the country.

In addition to the National Laws, we also State laws that prohibit the practice of FGM in Nigeria.  In this presentation, we want to highlight the laws in the five states where the UNFPA-UNICEF Joint Programme on Eliminating FGM is taking place such follows…

1. Female Circumcision (Prohibition) Law, 2002 (Ekiti State)
2. Osun State Female Circumcision and Genital Mutilation (Prohibition) Law 2004;
3. Violence Against Women Law, 2016 (Oyo State);
4. Imo state FGM (Prohibition) Law (2017); and
5. Ebonyi State Violence Against Persons (Prohibition) Law, 2018;   

In addition to the above laws, the existence of “Medical and Dental Practitioners (Disciplinary Tribunal) Rules” and “National Health Act 2014” also protects the girls and women from being subjected to FGM by medical practitioners as described in 33a and b.

Regarding medical malpractice, the Medical and Dental Practitioners (Disciplinary Tribunal) Rules, 2004 (the Medical Act), sets out in Section 16 under ‘Penalties for Professional Misconduct’ that, where a registered person (i.e. a medical practitioner) is found guilty of professional misconduct by the medical Disciplinary Tribunal or is convicted by any court of law or tribunal for an offence considered incompatible with the status of a medical practitioner, they may be subject to penalties. Although this does not explicitly refer to FGM, if such an action is considered as medical malpractice, it would thus fall under the scope of this law.

In addition, the National Health Act 2014 under Section 48(1) addresses the removal of tissue, blood or blood product from the body of another living person. The action is liable to prosecution unless it is done with the informed consent of that person, for medical investigations and treatment in emergency cases (where the consent clause may be waived) and in accordance with prescribed protocols by the appropriate authority. Section 48(2) also states, ‘A person shall not remove tissue which is not replaceable by natural processes from a person younger than eighteen years.’

The availability of FGM-related social and legal services essential in ensuring the accessibility of services to persons subjected to FGM and/or those at risk of undergoing the practice. However, there are some challenges that prevent them from accessing these services. 

in Nigeria where the culture of silence still surrounds FGM, in many quarters, a lot needs to be done to encourage women/girls to speak out when subjected or of threatened with this harmful practice. Therefore, the public needs to be aware that a survivor has the freedom and the right to disclose an incident to service providers. 

In Nigeria many women and girls who need FGM-related services may not have the financial willpower to access such services.  Therefore there is a need to ensure that some of these services are provided free-of-charge, or subsidized as the case may be.  The people also need to become aware of the existence of these services.

To address these challenges, there is also a need to harmonize the process involved of providing FGM-related legal services, by all government and non-government stakeholders at various levels, by establishing a Standard Operating Procedures (SOP) & Referral Pathway for service provision.

These referral pathways, with Standard Operating Procedures (SOPs), will serve for case management and by extension make easier for FGM survivors to access FGM-related legal services

The provision of these FGM-related services must focus on two linked aspects of care: (a) Provision of sensitive and appropriate services for survivors of FGM; and (b) Safeguarding girls at risk of FGM.  The nature of FGM services will vary depending on local prevalence of FGM, and in each case there must be clear referral pathways to FGM services. 

These organizations providing FGM-related services must thereafter commit to disseminate the SOPs and referral pathways in communities where they operate to ensure knowledge and improve access of FGM survivors to services (health, social and legal) and support.

At the bottom of the referral pathway, an FGM survivor may disclose her experience or threat of FGM to a trusted family member or friend. She may also seek help from a trusted individuals or organization.

Anyone the survivor tells about her experience has a responsibility to give honest and complete information about services (including legal) available and encourage her to seek help where available.

As earlier mentioned above, the survivor has the freedom to report the incident/event to anyone. She may seek help from community leaders, social workers, health workers or friends.

For each FGM case, the provider need to ensure that a written consent form is completed by the survivor describing the incident in her own words.

If the survivor is trying to escape FGM, she would still provide information on the event and provide her consent before protection or any other services are offered. Also, if the survivor is illiterate, her exact words should be written and read loudly to him/her to understand before he/she can indicate signature with a thumbprint.

Referrals should be made among the various government and non-government actors from those who first got the report to the actual legal service providers.

Where legal services are needed, the consent of the survivor has to be gotten and then referred to appropriate agency to provide security, protection and legal services, complete the incident form and document incident.

In each case where a referral is made, a follow up is necessary to ensure that services are provided, and also to ensure client satisfaction and safety.

All members of the organizations that receive the referrals must also be properly oriented on the guiding principles in the SOP for service provision.

Upon receiving initial report of a girl-child or woman who is threatened with FGM, the person who has this information should contact and make referrals to relevant agencies and organization for child protection. Amongst these relevant agencies and organization for child protection are the key actors will be Ministry of Health, Ministry of Women Affairs and Social Development (SMWASD), Ministry of Justice, National Human Rights Commission, International Federation of Women Lawyers (FIDA), Child Protection Network (CPN), Legal Aids Council, and others agencies providing similar services, especially Civil Society Organizations.  These agencies will make sure to abide by the procedures for caring for child survivors and should also utilize the applicable laws in the state to ensure protection of the child.

In the case of a child facing the complications of FGM, the service provider should also follow the steps and guide in the SOP and referral pathway to ensure access to urgent medical intervention.

On documentation, reporting and information management the SOP should adopt a format that will ensure that information on incident is systematically recorded and stored in a safe place.

Organizations who are signed on to this SOP should ensure that their staff members are oriented on how to complete the forms and interact with the survivor in line with the guiding principles.

Actors for this SOP must attend a Quarterly Review Forum to be to review successes, discuss challenges, share lessons learnt and work out the way forward.

There should be Annual or Biennial review of the SOPs. However, the referral pathways will continue to be reviewed as necessary by the actors as necessary to maintain relevance and focus.

In Nigeria, traditional and community leaders are major decision makers whose positions and opinions influence community behavior. Therefore, FGM response and legal services must integrate the actions and perceptions of this social group. Efforts will be made to educate, sensitize and include community and religious leaders who are FGM champions in the overall FGM response in the state as active actors in the referral pathways.

The Federal and State Governments should ensure that adequate funding is available for anti FGM programmes to disseminate clear and accurate information around the law, as well as the services available for FGM survivors and those at risk.

The Nigeria Police Force, Nigeria Security and Civil Defence Corps (NSCDC) and the judiciary need adequate support and training around the law and should be encouraged to apply sentences provided for by the legislation.

The Ministry of Justice and Judiciary should be encouraged to use Mobile Courts in fast-tracking the prosecuting of offenders. After serving their sentences, the convicted offenders and families are counseled to become change agents. This system has been found to be very effective in Burkina Faso.

The Judiciary could be encouraged to make sure any prosecutions relating to FGM are clearly reported, including by local media such as community radio, and made available in local languages.

The increased involvement of Community and religious leaders in education around the law, including their responsibilities and the importance of the law in protecting women and girls in their communities, should be encouraged.

Effective monitoring and collection of data around enforcement and cases of FGM would help to inform strategies and programmes.

Mandatory reporting of instances of FGM by medical staff in hospitals and health centers is recommended to ensure that now girl/women is left behind.

Where they are currently unavailable and a need is identified, appropriate protection measures (for example, emergency telephone lines or safe spaces, including temporary shelters) should be put in place for girls and women at risk of FGM.

Laws could be printed and widely distributed in local languages, to make them more widely available to the public, including in forms that can be used in areas of low literacy.

Local community radio and other media channels, including mobile phone technology and social media platforms, should also be considered for dissemination of information on the law and social services available in Nigeria.

Whatever the reason provided, FGM reflects deep-rooted inequality between the sexes. This aspect, and the fact that FGM is an embedded sociocultural practice, has made its complete elimination extremely challenging. As such, efforts to prevent and thus eventually eradicate FGM worldwide must continue, in addition to acknowledging and assisting the existing population of girls and women already living with its consequences whose health, social and legal  needs are currently not fully met.

At this juncture, I will like to stop and I will welcome questions and contributions.

To learn more about the @endcuttinggirls Social Media Campaign to end FGM, please visit endcuttinggirls.org and follow our social media handles on Facebook, Twitter, Instagram and YouTube, using @endcuttinggirls