By Ola MosesDecoda @olamosesdecoda

The effectiveness of a country’s health care delivery system is central in meeting its health goals.

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”.

The World Health Organization (WHO) has classified FGM into four types, and they are all practiced in Nigeria.

FGM 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.

FGM 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.

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).

Subgroups of Type III FGM are: type IIIa, removal and apposition of the labia minora; type IIIb, removal and apposition of the labia majora.

11c. Reinfibulation is covered under this definition. This is a procedure to recreate an infibulation, for example after childbirth when defibulation is necessary.

FGM Type IV: unclassified – all other harmful procedures to the female genitalia for nonmedical purposes, for example, pricking, piercing, incising, scraping and cauterization.

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.

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.  @WHO

For additional reading on FGM you can visit http://www.who.int and www.endcuttinggirls.org or watch https://www.youtube.com/watch?v=f0-dYD9cYKo&t=80s @WHO  @28Toomany

 A research by @ Population_Council 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. 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 mediclization of FGM in State like Imo State-61%; Delta State-28.9%; Ekiti State-26.2% and Kaduna-22.4%.   

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 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.

To end FGM in Nigeria, partnership with health workers is very essential and to ensure an end to medicalization of the practice.

With partnership with health care providers, they can become great Allies in the Efforts to end FGM using their different existing programmes and organizational structures. 

  • Advocates should be aware of some of the exiting health system programmes and organizational structures to enable them build a lasting partnership with health workers both at National, State, LGA and Community level. 
  • All three tiers of government – Federal, State and Local – share responsibilities for providing health services and programmes in Nigeria. 
  • The Federal Government is largely responsible for providing policy guidance, planning and technical assistance, coordinating state-level implementation of the National Health Policy and establishing health management information systems.
  • In addition, the Federal government is responsible for disease surveillance, drug regulation, vaccine management and training health professionals. 
  • The Federal Government is also responsible for the management of teaching, psychiatric and orthopaedic hospitals and also runs some medical centres.
  • The responsibility for management of health facilities and programmes is shared by the State Ministries of Health, State Hospital Management Boards, and the Local Government Areas (LGAs).
  • The states operate the secondary health facilities (general hospitals) and in some cases tertiary hospitals, as well as some primary health care facilities.
  • The training of nurses, midwives, health technicians and the provision of technical assistance to local government health programs and facilities are also the responsibility of the state authorities.
  • The 774 local governments oversee the operations of primary health care facilities within their geographic areas. This includes the provision of basic health services, community health hygiene and sanitation.
  • additionally, at Community level, there exist Community Health development Committee and Village health workers who could serve as end FGM advocates at LGA level.

Research suggests that there are several ways to win health care professionals’ support as allies in FGM abandonment efforts having in mind their programmes and organizational structures. 

First, training programs for these professionals, particularly those living in areas where FGM is widely practiced, should focus on what FGM is, why it is practiced, its health impacts, and ways to prevent it.

Trainings must also sensitize health care practitioners to the fact that FGM is a violation of girls’ and women’s rights to health and conflicts with the “do no harm” principle of medical practice.

Second, these professionals, as a focus of FGM abandonment programs, should be given the opportunity to reflect on their own beliefs and think critically about how these views may fuel the continuation of the practice.

Health professionals’ associations and health regulatory agencies should have clear guidelines and standards for providers that outline the sanctions on those who perform FGM. 

These organizations should also offer opportunities for health care professionals to contribute to community efforts to promote the abandonment of the practice.

Community health outreaches should include sensitization of the people on the dangers of Female Genital mutilation on the health of girls and women. 

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. 

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.

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 FGM, and laws and policies and/ or the application of existing laws and 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.

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 licenses withdrawn if they perform FGM.

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.

The involvement of the health sector is critical for gathering data and broadening national monitoring mechanisms. Necessary actions in this area are to:

  • monitor health-sector training and implement the lessons learned.
  • Develop mechanisms to increase accountability at facility and district levels;
  • Routinely collect data on FGM (e.g. antenatal records).
  • Monitor providers of FGM, including legislative measures taken against them.
  • 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.)
  • Report to UN human rights treaty bodies and other international and regional human rights bodies; and institutionalize feedback mechanisms to the communities.

The role of the health sector in the campaign to end Female Genital Mutilation cannot be overemphasized.

To explain the role of the health sector in providing FGM related services, I will divide the services the health sector provides into two broad group, namely, Pre – mutilation services and Post-Mutilation services

  • ThePre – mutilation services are those FGM related health services are rendered by Doctors, nurses, midwives and other health personnel.
  • Pre – Mutilation services are services that can be rendered to women or girls who have not been cut and includes; health education, counselling of pregnant mothers and their spouses etc.
  • Post Mutilation Services are services that can be rendered to women or girls who have been cut and includes; counselling, Therapy, Deinfibulation for women that have undergone infibulation, reporting of offenders.
  • De-infibulation refers to the practice of cutting open the sealed vaginal opening in a woman who has been infibulated which is often necessary for improving health and well-being as well as to allow intercourse or to facilitate childbirth.

In order to enhance the quality of FGM-related health services in Nigeria, special attention has to be given to the training and equipping of health personnel with skills necessary to the delivery of these services.

The government and other parastatals have a huge role to play in this training and making these services available and accessible

Health personnel should be trained from time to time and be given up to date information about FGM especially as regards Medicalization as a lot of people erroneously believe it is beneficial.

By educating them they would be able to also provide adequate information to their patients about the dangers of FGM especially expecting mothers, couples amongst others.

Counselling is one of the major services that health personnel have to provide especially to FGM survivors as regards how to cope with the long- and short-term effects of FGM

Some women who have undergone FGM suffer from psychological problems including; depression, post-traumatic stress disorder (PTSD) amongst others, it is essential that hospitals have health personnel (psychiatrists) that can manage these conditions.

Providing health personnel with adequate counselling skills and emotional intelligence training is hence also a vital part of improving the quality of health services provided by them.

Special health education about FGM should also be given in antenatal clinics to expecting mothers

If need be counselling sessions should be organized for families of women who think that their families won’t agree not to cut their girl child

Health personnel should also be willing and prepared to answer all questions that their patients may have as regards FGM

Hospitals should be provided with materials, equipment and manpower to carry out FGM related procedures such as de-infibulation, vesico-vaginal fistula surgeries etc.

Health personnel should also be informed that they should inform the appropriate authorities about people who still went on to cut their girl child as laws have been made against FGM in Nigeria

Health personnel in Nigeria are generally viewed as trustworthy people whose opinions are mostly always respected. Hence by providing correct and adequate information about FGM to their patients they can help to eliminate FGM.

In conclusion, FGM violates human right, ethical principle of justice, beneficence and non maleficence and the medical code of ethics.

Health workers took part in this oat to save lives and FGM is a life-threatening practice therefore the partnership of health care providers is needed to curb the practice.

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

At this point, I will end the presentation to give room for questions and contributions from participants. Thank you all for reading our tweets

Together we will end FGM in this generation.