My decision as a mother to not cut my daughters

By Masuma Kothari

Country of Residence: United Kingdom

A vivid memory of my cut has lived through so many years that I can recall the entire act. This experience always intrigued me and it did lead me to the insights of child psychology as to how tender a 7-year-old is. Even though my personal experience was not very excruciating, I clearly remember the sense of betrayal, and it never went away.

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I was never convinced with the benefits theory that was proclaimed, and honestly, nobody really knew at a deeper level the real reason to follow this practice when I sought guidance. Because of the social influence, it was apparent that herd mentality, unexposed details, unquestioned thoughts promoted this practice.

When my elder daughter was near the age, I had to figure out for myself if my daughter should also be cut. It felt as if I had Godlike power to alter something natural belonging to my daughter’s body forever, and that did not feel right. For me, the decision was a chaotic fight between the cultural beliefs and the scientific quest. I reached out to a few of my doctor family members to understand if there was any scientific aspect. All of them discouraged the practice. That is when the light in my heart beamed strong.

I chose courage and discussed this openly within my group of Bohra friends. Surprisingly, I found most of the women were also against it and this strengthened my defiance! In fact, my mother secretly regretted having the practice done to me, too.

I was sure I did not want to take away what God had bestowed on my daughters. With this clarity, I announced it to my family that we won’t be conducting this on our daughters. One additional powerful advantage was that we resided in the United Kingdom. Since it is a criminal offence here, it was an easy argument to assure a few of our noisy family members back in India.  Because we as parents were strong, nobody really questioned or bothered to enforce this. It was simply about standing up for what we thought to be correct.

My husband was firm from day one that he was not willing to get this done for our daughters, yet he had given me the ownership of making this decision in case I was convinced that it had to be done. My decision scale had a chunky weight on anti-FGM, which was also a major influence in my decision to not cut my daughters.

There is absolutely no need to do this. If you are a parent struggling with the obligation to have this done, just say no to this age-old trauma-enabling practice and move on guilt- free with loud pride that you have made the right choice.

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Locating female genital cutting through films and documentaries

By Debangana Chatterjee

Though films and documentaries related to female genital cutting (FGC) promise to uphold the realities surrounding the subject, there are undeniable strings of subjective interpretations attached to them. Thus, rather than becoming ‘real’, these films and documentaries transpire as the reel portrayal of realities. Desert Flower, a 2009 German production is the most pertinent feature film on the subject based on Waris Dirie’s 1998 autobiographical account of the same name. In the realm of popular culture, the film relegates the practice of FGC being coterminous to infibulation, whereas infibulation is one of the most extreme variations of the four types of FGC, as has been classified by the World Health Organisation (WHO). Rather than providing the holistic imagery of the practice, this film portrays a partial picture of it.

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Desert Flower

The documentaries on FGC are majorly driven for either anti-FGM awareness campaigns conducted by various international organizations, or for journalistic ventures of finding and documenting facts by renowned media houses from across the globe. Some of these major documentaries include Warrior Marks (1994), The Cut (2009), The Cutting Tradition (2009), ‘I Will Never Be Cut’: Kenyan Girls Fight Back against Genital Mutilation (2011), A Pinch of Skin (2012), The Cruel Cut – Female Genital Mutilation (2013), True Story – Female Genital Mutilation in Afar, Ethiopia (2013), Reversing Female Circumcision: The Cut that Heals (2015), The Cut: Exploring FGM (2017), Jaha’s Promise (2017), Cutting the Cut (2018). Another talked about documentary of 2018, Female Pleasure, though does not solely deal with FGC, features the renowned activist against FGC Leyla Hussain to shed light on the practice as a mode of controlling female sexuality. With the exception of A Pinch of Skin and Cutting the Cut that focuses on the particularities of the practice in India and Kenya, respectively, from an internal vantage point, others make cultural commentaries on the practice from the perspective of anti-FGM advocates.

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A Pinch of Skin

Cutting the Cut was produced in 2018 under the aegis of The Health Channel in Kenya. Winnie Lubembe, a Kenyan herself, is the narrator, producer, and writer. With a special focus on the Maasai community of Kenya, the documentary presents both against and for narratives of the practice. On the one hand, it discusses the hazardous aspect of the practice. On the other, views supporting legalization of the practice are also presented, as it arguably promotes medicalization as well as cultural preservation. The non-alienation of the community and the need for complementing legal banning with adequate awareness programmes and cultural redressal are the two main takeaways of the documentary. It also highlights the political nuances operating through the legal state apparatus.

A Pinch of Skin, on the other hand, is a 2012 Indian production directed by Priya Goswami. This can be designated as one of the maiden attempts to shed light upon the practice among the Bohra women in India. The maker, despite not belonging to the cultural community, makes honest attempts to put herself into the shoes of the believers, and thus, brings out voices both pro and against the practice. In fact, the naming of the documentary is indicative given that it does not merely portray the practice as ‘gruesome’ and ‘barbaric’. Rather it highlights the practice of nicking the tip of the prepuce of the clitoris, prevalent among the Bohras.

A Pinch of Skin film Poster (1)
A Pinch of Skin

Barring these two, representations through visuals of the cultural ‘other’ from an external vantage point appear to lack intricacies and layers. For example, The Cut: Exploring FGM, The Cruel Cut- Female Genital Mutilation, and The Cutting Tradition are produced respectively by Al-Jazeera, Channel4 and SafeHands for Mothers in collaboration with the International Federation of Obstetricians & Gynaecologists (FIGO), respectively. The Cut, directed by  American-journalist Linda May Kallestein, has also been funded by multiple Norwegian agencies. Most of these representations are located beyond the cultural purview and thus, lack empathy in their cultural portrayal. Though The Cruel Cut- Female Genital Mutilation and Jaha’s Promise feature Somali activist Leyla Hussein and Gambian activist Jaha Dukureh respectively, it is to be reminded that the onus ultimately lies at the hands of the creative teams of these documentaries. Even Jaha’s Promise uses one of the clips from Barack Obama’s speeches where he is referring to the practice as ‘barbaric’ which as a term is discredited for its blatant cultural insensitivity. It is problematic to assume that the mothers always put their daughters through the practice intentionally being fully aware of its consequences. Fatma Naib, the presenter of The Cut: Exploring FGM, an Eritrean immigrant to Sweden, showcases details of the state of the practice in Somalia and Kenya with substantial subtlety so far as it highlights campaigners against the practice from within these cultures. As a whole, it is not merely about the geographic positioning of the creative teams but about the outlook that they share while describing cultural specificities.

Nuances and variations of the practice are not adequately showcased in many of these films. For example, out of all the countries with reported cases of FGC, African countries especially, Kenya, Somalia, Ethiopia, and Egypt are highlighted out of proportion. It is largely because of the rampant prevalence of the practice mainly in these countries. It is to note that only 10 percent of reported cases worldwide are the most severe and may fall into the category of infibulation- even in Africa. Notwithstanding the need to highlight the regions with a higher percentage of the practice, these documentaries seem to make convenient choices so far as the cases are concerned. This comes hand in hand with exoticization of pain. For instance, the documentary True Story – Female Genital Mutilation in Afar, Ethiopia, starts with the representative audio of excruciating scream of a newly-wed girl who dies out of profuse bleeding due to forced penetration of her infibulated vagina. This scream is followed by figurative graphics of a splash of blood accompanied by a heart-wrenching narration of the incident. The Cutting Tradition with its explicit emphasis on four African countries including Egypt, Ethiopia, Djibouti, and Burkina Faso, uses substantial, real visuals of the practice. The cultural orientation of these representations is reflective of a cultural aversion toward the unintelligible culture. The visual knowledge of the matter, thus, gets constructed from a position of power going in tandem with the existing Western liberal discourse.

Though there are well-intentioned attempts to bring out hard-hitting facts regarding such sensitive subjects, in many cases such intentions get mired with preconceived prejudices. Notwithstanding the possibilities of becoming judgemental even after belonging to the same culture, it is important to understand the outlook of the makers. Needless to say, the making of films and documentaries are driven by factors of storytelling or awareness-raising and are thus, difficult to be objectively oriented. Attempts to bring out different sides of various cultures, giving voices to women of these communities who break the shackles of conformity may pave the way for a ‘real’ and relatively balanced depiction of realities in regard to FGC.

A Nigerian Nurse’s Perspective on Female Genital Cutting

By Brionna Wiggins

Female genital cutting (FGC) occurs in many countries around the world. Through my future posts, I hope to explore a few of these places by meeting with those who can speak on them. Many African countries and countries in the Middle East have been reported to have a large concentration of practicing communities. However, FGC is not limited to these areas, nor is it practiced by every single person in these regions. Recently, I spoke with Uzokau Chukwu, a registered nurse, about her thoughts on FGC.

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Brionna Wiggins with Uzokau Chukwu

Mrs. Chukwu is from a community in Imo State, Nigeria, where she spent her childhood until age 13, before moving to the United States. To her knowledge, FGC was not practiced  in the place she grew up. Instead, her community does an alternative practice, a tradition entirely without blood or cutting, where the area above the pubic bone is massaged.

“Older women in my village says it’s to reduce the sensation of a girl being overly sexed,” she said.  “They don’t cut anything.” According to her community, it still meets the security needs of those who fear raising a promiscuous daughter without cutting away at the body.

Mrs. Chukwu didn’t hear of FGC until she came to America and began her medical studies later in life. She worked alongside a student who came from a country with a high prevalence of FGC, so the topic was analyzed through an infection-control perspective.

The practice of FGC brings up health concerns, as girls may be laid directly on the ground for the procedure, and there is risk of severe injury or death. The operation may be done in a setting without sterile equipment.

“People were saying that some girls are dying after they go through that procedure,” she said. “They bleed to death or, you know, they cut so much nerve or into something, and then the places where they’re doing those things are not clean.”

Additionally, Mrs. Chukwu is left to ponder a handful of questions. How do practicing societies know if FGC works to reduce sexuality? Do they have alternatives? Did they notice a vast difference between those who are cut and uncut? Who came up with this practice? Who deemed it to be right? More importantly, who asks the girl for proper consent?

I agree with Mrs. Chukwu that FGC might be a slightly different matter if FGC was limited to consenting adult women rather than young girls. However, the idea of “cutting into someone’s body,” especially having to hold down the person as the procedure goes on, is disturbing. Although it goes without saying (I still asked), Mrs. Chukwu wouldn’t have herself, her daughters, or anyone else undergo the procedure. She wondered in passing if she was being too harsh in judging those who have their girls cut, but she also demanded concrete evidence that the cutting had any medical benefits at all. Ultimately, Mrs. Chukwu fears that FGC perpetuates the second-class status of women worldwide.

The conversation on FGC is definitely opening up to the general public on a worldwide scale as awareness grows. Admittedly, it’s hard to convince others to abandon FGC, as to do so is to challenge their beliefs, especially since it’s a practice that has persisted for generations. Hopefully, increased advocacy against FGC will spike awareness of its detriment to women and society.

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Brionna is currently a high school senior in the District of Columbia. She likes drawing, helping others, and being able to contribute to great causes.

A mother’s side of the story on female genital cutting

By Priya Ahluwalia

Priya is a 22-year-old clinical psychology student at Tata Institute of Social Sciences – Mumbai. She is passionate about mental health, photography, and writing. She is currently conducting research on the individual experience of khatna and its effects. Read her other articles in this series: Khatna Research in Mumbai.

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The proverb, “It takes a certain courage to raise children,” rings true, especially since much of the responsibility for a child’s development rests solely on the parental system. The parents significantly influence a child’s development, since the social connection formed with them serves as the prototype for all their future interactions. Through this parental interaction, the child learns values, traditions and learns to understand the culture. Within the cultural context of India, much of this responsibility shifts onto the shoulders of the mother. Due to the proximity and consistent presence of the mother, the child is naturally attuned to her and views her as their primary caregiver responsible for providing love, warmth, and protection. Any adversity experienced by the child may be seen as the mother’s inability to fulfill her responsibilities.

Similarly, in the case of khatna, which is a custom among the Bohri Muslims in India which involves partial or total removal of the clitoris, girls may subconsciously blame their mother for failing to “protect” them, although women understand that culture and tradition are responsible for the pain they experience. In my own research, when I conversed with participants I found that even when another female member takes them to be cut, the blame rests upon the mother alone. Initially, I found myself puzzled on this discrepancy in attribution. But during in-depth conversations with my participants, I found that all of them “trusted” their mothers to love them and to protect them. They stated that their mothers had “broken my trust” by continuing a practice without even attempting to understand its implications. Thus, the participants were angry because they had been betrayed. This experience has been discussed significantly in other research, as well. However, I wondered about the kind of emotions elicited in the mothers who were at the receiving end of their daughter’s anger.

Fortunately, I had the opportunity to talk to mothers. Through conversations with them, I found that even the mothers have been significantly impacted by the revelation that they had done wrong to their daughters. From a mother’s perspective, her world is crashing down as well. Through all these years she has developed a belief that khatna is good. It may make her daughter belong to their community. it may keep her safe. She acts on this belief with good intentions of protecting her daughter and doing what she believes is her motherly duty. As her child grows up, she does many such acts with good intentions to protect and love her daughter. Throughout her life, the mother forms the belief that I am a good mother who has checked off all the boxes. Several years later, she may find herself in a situation where she is now bearing the brunt of her daughter’s anger because she has failed to protect her child from harm, particularly of khatna. This revelation shatters a belief in khatna she may have fostered for more than half of her life.

In therapy, we always say that beliefs are the most difficult psychological construct to work with because all beliefs are interconnected. These interconnections form the self of a person. When one belief is broken, it causes a chain reaction where the other beliefs begin to be questioned. The same happens with a mother. Post-revelation she begins to question every aspect of her life, her identity, and her essence. A mother may then feel an overwhelming sense of failure and inadequacy. Biologically speaking, whenever we are overpowered, our fight or flight responses kick in. Therefore, the mother may respond to her pain with anger and denial. It is helping her keep her sense of integrity intact.

When the mother responds in anger and denies having done anything wrong, the impact it has on the survivor is severe It heightens her emotions.  It’s important to remember that both the mother and the survivors are fighting their own battles. Both parties need time to process this shock. Thus, it is essential that the space for change is provided by both sides.

Some of the pointers to remember during this time that are applicable to both the survivors and the mothers:

  • Remain empathetic. Both of you may be struggling.
  • Be kind. Do not raise your voices while talking. Do not accuse each other.
  • Listen when the other person talks. Both of you have the right to say your part.
  • Have conversations outside the purview of khatna.
  • Establish some routines with each other: eat together or go for walks together.
  • Respect each others’ decisions.

The dynamics of a relationship are bound to change once such an intense conversation takes place. It is essential that during this time of transformation, a sense of support for each other is established. At the same time, it may be difficult to do so, but it is imperative that this be done if the new dynamics are to mimic the love, warmth, and comfort that may have been present in the previous relationship. My participants themselves mentioned that although the dynamics between them and their mothers have changed, with time and space their bond has only become stronger.

A message to the survivors, you have the right to be angry. You have the right to be heartbroken. Give yourself time to feel all these emotions. Take care of yourself. Access some helpful resources.

For mothers who regret their decisions but do not know what to do, apologizing always helps. Not only would it heal you, but it may heal your daughter, as well.

For mothers in the dilemma of whether they should perform khatna on their daughters, please don’t do it. A life full of pain and regret is no way to live, neither for you and nor for your daughter.  

A response to the letter written by Tasneem Yunus Burhani, Mubaraka Tambawala, Farida Mustafa Hussain, Fatemah Hussain, and Shakera Bohra published in Detroit News

By Umme Kulsoom Arif

In response to your letter published in The Detroit News,Dawoodi Bohra Women of Detroit speak up,” I write to you as a woman who grew up in a part of the Dawoodi Bohra community, just like you. I am also a woman of faith and education, a woman who loves her country as well as her Dawoodi Bohra community, who balances religion and patriotism in a trying, divisive time. And just like you, I am frustrated and saddened by the propaganda and misinformation that has spread surrounding the case of Dr. Jumana Nagarwala because I too am a survivor. A survivor of a harmful practice that violated my human rights, robbed me of my personal integrity, and — in punishing me for my own femininity — left me permanently scarred, both mentally and physically: khaftz.

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You claim that khaftz “in no way can be defined as female genital mutilation,” but do you know what FGM even is? The World Health Organization defines FGM/C as “all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.” So educate me, then — what is the medical reason for khaftz? Why must it be done? Why must a girl be lied to, held down, or drugged so that a blade can be taken to her genitals and a part of her clitoris sliced away?

You call the procedure “harmless,” so I ask you — where does the harm begin in your minds? Where do you draw the line between the “ritual” you defend and the “more barbaric practices from around the world” you claim to condemn? Is it not harmful to deny your daughter the right to her own bodily autonomy? Is it not harmful to violate her right to be free of torture and degrading treatment and to teach her that her body is “wrong” and must be surgically altered based on the words of religious men?

The Quran does not ask this of us, so I ask you — who does? When countries around the world — including the United States — have signed human rights treaties both condemning and outlawing all forms of FGM, who demands that our daughters be subjected to a cutting or scraping without their consent and with no medical reasoning behind it?

Though you claim to be patriotic Americans who follow all the laws of the land, you challenge a law meant to protect the most vulnerable members of the country’s population — its children. How can you in good conscience, claim that khaftz is “much more akin to a body piercing” when a child would never consider getting a piercing in such a sensitive area?

Many of you are lucky to have suffered no consequences — physically or mentally — from khaftz, but your experiences are far from universal. You lie to yourselves when you purport to be representative of all the survivors of the khaftz. You lie to your daughters when you claim that there are no negative effects to the practice. You do a disservice to your community when you hide the truth of this harmful form of gender-based violence behind pleas for tolerance and claims of political persecution. By claiming that your experiences are universal and by defending this harmful practice, you have a direct hand in perpetuating violence against women.

Is that the future of the Dawoodi Bohra community? A future where we must look our children in the eyes and tell them that they have no ownership of their bodies? A future where our daughters must be subjected to sexual trauma and placed at risk for future infection, for future complications in childbirth, or for chronic pain in a most sensitive area? The Dawoodi Bohra community cannot adhere to archaic violence in the name of tradition. The world around us has changed, and today we know more about our bodies and the consequences of our actions than we ever did. We must grow as people, as a community. We must come together to help, not harm.

You may be educated women, but you blind yourself to the true nature of khaftz and its harm. You beg for tolerance and understanding but you do not try to understand the pain you inflict on your daughters when you have them cut. I beg you to take the time to listen to women the world over who have been harmed by khaftz.

Read also “Other Views on FGM.”

Female Genital Cutting is an International Issue

By Brionna Wiggins

Upon hearing about female genital cutting and what it entails, it seems that one of the first facts you hear about it has to do with its prevalence in Africa and the Middle East. While it is true that these continents have a high prevalence (which has been decreasing according to a recent study by BMJ Global Health), it may contribute to the misconception that these are the only places in the world where females undergo FGC. Unfortunately, this is not the case. This practice reaches Asia, Europe, North America, South America, and Australia. Its presence on multiple continents leads FGC to be an international issue that needs to end with the support of all the nations involved.

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Map Courtsey of Orchid Project
As part of my senior project, I have been bestowed the opportunity to do volunteer work with Sahiyo. They work specifically with the Dawoodi Bohra community, whose members mainly reside in India, Pakistan, Yemen and East Africa. FGC is also prevalent in countries such as Malaysia and Indonesia. There have even been reports in Colombia, South America. This puts FGC on every continent in the world!

As previously mentioned, FGC occurs among diaspora communities. When families from countries that practice FGC move into new areas, they inevitably bring along the instilled need to continue the social norm. This leads to FGC being present in ‘receiving countries’, which can include places bordering practicing countries. Despite the handful of receiving countries that ban and criminalize FGC, the practice is still inflicted on girls in an effort to maintain their cultural identity. However, diaspora community members may send their daughters to their home country for ‘vacation cutting’. FGC is not a practice that is restricted by borders. Decades ago, FGC was practiced in some of the same countries that worked to prevent it.

In Victorian Era England, FGC ushered its way into the medical field as a cure for nervous diseases, masturbation, and any other infliction that doctors/surgeons related to the female organs. Gynecological surgeon Isaac Baker Brown popularized the idea of using clitoridectomy, or removal of the clitoris, as a solution for ailments in medical circles. After some time, Isaac Brown and those who followed this method were eventually condemned. Yet, it was not so readily removed from American medical textbooks. Doctors in the U.S. also continued with this treatment to cure female ailments and the last documentation of this practice dates as far back as 1947. It is the year Renee Bergstrom received a clitoridectomy at the age of three in “white, midwest America” (The Guardian). People with good intentions may harm others irreparably, even the ones who trust them the most.

While the practitioners may mean well, it still doesn’t excuse the continual physical and psychological harm of women and young girls. These mistakes have been made before, and are still being made by participating societies and people who perpetuate the practice. With FGC being so close to home, the problem cannot be ignored any longer as someone else’s problem. This practice affects women and girls on every continent. It must be dealt with using the full support of every global citizen to end the practice of FGC for the sake of women and men. You can help advocate against it too. Research is crucial in understanding a multifaceted issue such as this to ensure and reaffirm what you’re advocating for. That’s when you can volunteer your time or voice to organizations working to end FGC and keep up to date on the topic. Also, you can inquire about the laws in your state if they regulate or have anything in place pertaining to the practice. If there’s not a law already, then you can advocate for one being created.

 

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Brionna is currently a high school senior in the District of Columbia. She likes drawing, helping others, and being able to contribute to great causes.

Trauma and Female Genital Cutting, Part 6: Effects of FGM/C on the Lower Urinary Tract System

(This article is Part 6 of a seven-part series on trauma related to Female Genital Cutting. To read the complete series, click here. These articles should NOT be used in lieu of seeking professional mental health and counseling services when needed.)

By Julia Geynisman-Tan, MD

Background

FGM/C has no known health benefits, but does have many immediate and long-term health risks, such as hemorrhage, local infection, tetanus, sepsis, hematometra, dysmenorrhea, dyspareunia, obstructed labor, severe obstetric lacerations, fistulas, and even death. While the psychological, sexual, and obstetric consequences of FGM/C are well-documented (refer to prior posts in this series), there are few studies on the urogynecologic complications of FGM/C. Urogynecology is the field of women’s pelvic floor disorders including urinary and fecal incontinence, dysfunctional urination, genital prolapse, pelvic pain, vaginal scarring, pain with intercourse, constipation and pain with defecation and many other conditions that affect the vagina, the bladder and the rectum. Urogynecologists are surgeons who can both medically manage and surgically correct many of these issues.

FGM/C and Urinary Tract Symptoms

One recent study from Egypt suggested that FGM/C is associated with long-term urinary retention (sensation that your bladder is not emptying all the way), urinary urgency (the need to rush to the bathroom and feeling that you cannot wait when the urge comes on), urinary hesitancy (the feeling that it takes time for the urine stream to start once you are sitting on the toilet) and incontinence (leakage of urine). However, the women enrolled in this study were all presenting for care to a urogynecology clinic and therefore all of them had some urinary complaints so it is difficult to tell from this study what the true prevalence of lower urinary tract symptoms are in the overall FGM/C population.

Therefore, given the significant number of women with FGM/C in the United States and the paucity of data on the effects of FGM/C on the urinary system, my research team studied this topic ourselves in order to describe the prevalence of lower urinary tract symptoms in women living with FGM/C in the United States. Publication will be available online in December 2018.

We enrolled 30 women with an average age of 29 to complete two questionnaires on Overactive bladder 1their bladder symptoms. Women in the study reported being circumcised between age 1 week and 16 years (median = 6 years).

  • 40% reported type I
  • 23% type II
  • 23% type III
  • 13% were unsure

Additionally, 50% had had a vaginal delivery; and 33% of these women reported that they tore into their urethra at delivery.

Findings:

A history of urinary tract infections (UTIs) was common in the cohort:

  • 46% reported having at least one infection since being cut
  • 26% in the last year
  • 10% reported more than 3 UTIs in last year
  • 27% voided ≥ 9 times per day (normal is up to 8 times per day)  
  • 60% had to wake up at least twice at night to urinate (once, at most, is normal)

Most of the women (73%) reported at least one bothersome urinary symptom, although many were positive for multiple symptoms:

  • urinary hesitancy (40%)
  • strained urine flow (30%)
  • intermittent urine stream (a stream that starts and stops and starts again) (47%) were often reported
  • 53% reported urgency urinary incontinence (leakage of urine when they have a strong urge to go to the bathroom)
  • 43% reported stress urinary incontinence (leakage of urine with coughing, sneezing, laughing or jumping)
  • 63%reported that their urinary symptoms have “moderate” or “quite a bit” of impact on their activities, relationships or feelings

What’s the Connection Between FGM/C and Urinary Symptoms?

Urinary symptoms like the ones described above can be the result of a number of factors. pee-night-400x322Risk factors for urinary urgency and frequency, incontinence, and strained urine flow include pregnancy and childbirth, severe perineal tears in labor, obesity, diabetes, smoking, genital prolapse and menopause.

However, given the average age of women in our sample and the fact that only half of them had ever had a vaginal birth, the rate of bothersome urinary symptoms are significantly higher than has been previously reported. FGM/C may be a separate risk factor for these symptoms. Interestingly, the prevalence of urinary tract symptoms in our patients closely resembled that of a cohort of healthy young Nigerian women aged 18-30, in which the researchers reported a prevalence of lower urinary tract symptoms of 55% with 15% reporting urinary incontinence and 14% reporting voiding symptoms. The authors do not mention the presence of FGM/C in their study population but the published prevalence of FGM/C in Nigeria is 41%, with some communities reporting rates of 76%. Therefore, it is likely that many of the survey respondents had experienced FGM/C, thereby increasing the prevalence of lower urinary tract symptoms in their cohort. In the study of women in Egypt referenced above, those with FGM/C were two to four times more likely to report urinary symptoms compared to women without FGM/C.

The connection between FGM/C and urinary symptoms can be understood from the literature on childhood sexual assault and urinary symptoms. Most women who experience FGM/C recall fear, pain, and helplessness. Like sexual assault, FGM/C is known to cause post-traumatic stress disorder, somatization, depression, and anxiety. These psychological effects manifest as somatic symptoms. In studies of children not exposed to sexual abuse, the rates of urinary symptoms range from 2-9%. In comparison, children who have experienced sexual assault have a 13-18% prevalence of enuresis (bedwetting) and 38% prevalence of dysuria (pain with urination). The traumatic imprinting acquired in childhood persists into adult years. In a study of adult women with overactive bladder, 30% had experienced childhood trauma, compared to 6% of controls without an overactive bladder. There is a neurobiological basis for this imprinting. Studies in animal models show that stress and anxiety at a young age has a direct chemical effect on the voiding reflex and can cause an increase in pain receptors in the bladder. Additionally, the impact of sexual trauma on pelvic floor musculature has been well described. Women who experience genital trauma often respond with an involuntary contraction of the pelvic floor, which can develop into non-relaxing pelvic floor dysfunction and subsequent urinary hesitancy, strained flow, retention, bladder pain and overflow incontinence.

These Conditions are Treatable

There are treatments for all of the conditions. Urinary hesitancy, strained flow, bladder pain, and urgency are often treated with pelvic floor muscle therapy. That is because many of these symptoms come from an unconscious, constant clenching of the pelvic floor muscles, which then prevents them from using their full range of motion and pinches off the nerves running through the muscles. Pelvic floor therapy focused on lengthening and stretching these muscles can completely change the way that you urinate and the sensation of pain in the pelvis. This kind of physical therapy is done by all female providers in a private room. The therapy consists of a combination of external and internal work on all of the muscles of your core and pelvic floor to release trigger points of tension and teach you how to relax and lengthen these muscles. Sometimes the therapists use biofeedback devices in the vagina to help you to recognize certain muscles groups. The sessions are usually one hour long and last for 6-12 visits. You can obtain a referral to a pelvic floor physical therapist from your local urogynecologist.

If you have urinary leakage throughout the day or nighttime, this can also be treated. Your urogynecologist can help differentiate whether you have stress urinary incontinence (leakage with coughing, laughing, exercise, lifting) or urgency urinary incontinence (leakage that follows the urge to go to the bathroom or sometimes sporadic leakage without any urge). These types of incontinence are treated differently but both can be treated with a combination of medicine, office procedures or surgical treatments. To find a urogynecologist in the Unit, you can go to the website of the American Urogynecologic Society and click on patient services.

 

About Julia Geynisman-Tan

Julia is a Female Pelvic Medicine and Reconstructive Surgeon in the Department of Obstetrics and Gynecology at Northwestern. During her residency at New York Presbyterian – Weill Cornell, she founded the Survivor Clinic of New York City, a dedicated clinic for women who had experienced sexual violence, including trafficking, female genital mutilation, and torture in war. Now in Chicago, Dr. Geynisman-Tan has founded the Northwestern ERASE Clinic for survivors of human trafficking and is an asylum evaluator for Physicians for Human Rights. She is currently a co-chair of the American Women’s Medical Association Physicians Against Trafficking of Humans Committee, on the board of the America Hospital Association’s Human Trafficking Consortium and serves on the Cook County Human Trafficking Task Force.