The Disturbing Trend of Medicalising Female Genital Mutilation

by Lorraine Koonce-Farahmand

In the Zero Tolerance campaign to end Female Genital Mutilation (FGM), what has been noted is the arc of progress. Increasingly, women and men from practising groups have declared support for ending FGM; and in several countries, the prevalence of FGM has decreased significantly. A BMJ Global Health study reported that the rates of FGM have fallen dramatically amongst girls in Africa in the last two decades. Using data from 29 countries going back to 1990, the BMJ study found that the biggest fall in cutting was in East Africa where the prevalence rate dropped from 71% of girls under 14 in 1995, to 8% in 2016.  Some countries with lower rates – including Kenya and Tanzania, where 3-10% of girls endure FGM – helped drive down the overall figure. Nevertheless, UNICEF’s groundbreaking report shows that whilst much progress has been made in abandoning FGM, millions of girls are still at risk.

FGC infographics_3

Flourishing against this backdrop is the compromise of medicalisation of FGM that competes against progress in the Zero Tolerance Campaign. A disturbing number of parents are seeking out healthcare providers to perform FGM. According to the World Health Organization (WHO), medicalisation is when a healthcare provider performs FGM in a clinic or elsewhere. Such procedures are usually paid for under the assumption that medicalisation is not FGM, and is done to mitigate health risks associated with the practice. Consequently, in recent years, the medicalisation of FGM has taken place globally, particularly in Egypt, Indonesia, Kenya, Malaysia, Mali, Nigeria, Northern Sudan, and Yemen. In many of these countries, one-third or more of women had their daughters cut by medical staff with access to sterile tools, anesthetics, and antibiotics. The non-governmental organization, 28 Too Many has investigated the involvement of health professionals and has highlighted what must be done to reverse this trend. 28 Too Many reported that the medicalisation of FGM in Egypt is an enormous challenge. Currently, 78.4% of incidences of FGM in Egypt are carried out by health professionals. Egypt had the highest rate of health workers performing FGM at 75%, with Sudan at 50% and Kenya at 40%. A 2016 study by The United Nations International Children’s Emergency Fund (UNICEF) and the Africa Coordinating Centre for the Abandonment of FGM/C (ACCAF) also found that FGM is increasingly being performed by medical practitioners.   

Parents and relatives seek safer procedures, rather than outright abandon FGM. The medicalisation trend has conveniently forgotten that FGM violates women’s and children’s human rights to health, to be free from violence, to have the right to physical integrity and non-discrimination, and to be free from cruel, inhumane, and degrading treatment. The “just a nick” is essentially gender-based violence (GBV). What is being “nicked” is still part of a woman’s labia majora, labia minora or clitoris. The medicalisation of FGM perpetuates that women are inferior human beings. This is not in harmony with international human rights standards.

There is also clearly an economic incentive for promoting medicalisation. Medical personal perform it for financial gain under the premise that if the crux of the issue is the health side effects and pain, by using sterilised instruments and medication the problem has dissipated. The misguided assertion that medicalisation is a viable option is ignoring the fact that all types of FGM have been recognised as violating human rights. These rights that have been codified in several international and regional treaties mirror worldwide acceptance and political consensus at various UN world conferences and summits. Committees such as The Committee on the Elimination of All Forms of Discrimination against Women, (CEDAW), the Committee on the Rights of the Child, and The Human Rights Committee have been active in condemning FGM. Medicalisation goes against the principles enshrined in these treaties and conventions.

The disturbing medicalization trend continues to argue that this less severe form of FGM can protect girls and women from harm. This was echoed in The Economist article of June 18th, 2016, Female Genital Mutilation: an Agonising Choice’. In the article, it was asserted that because three decades of campaigning for a total ban on FGM have failed, a new approach is warranted. The article advocated “nicking” of girl’s genitals by trained health professionals as a lesser evil. This reasoning was echoed in the Journal of Medical Ethics by two U.S.-based doctors, Dr. Kavita Shah Arora, Director of Quality, Obstetrics, and Gynaecology at the MetroHealth Medical Center in Cleveland, and Dr. Allan Jacobs, Professor of Reproductive Medicine at Stony Brook University. They wrote that “we must adopt a more nuanced position that acknowledges a wide spectrum of procedures that alter female genitalia.” They assert that they do not believe minor alterations of the female genitalia reach the threshold of a human rights violation. They also asserted that the nicking of the vulva and removing the clitoral hood should not be considered child abuse. They posit that by undergoing these acceptable procedures in the U.S. during infancy, girls can avoid the risk of being sent abroad for more extensive procedures.

These doctors and writers from influential respected journals are often held in high esteem by decision-makers, policy-makers, and experts. However, the advocation of medicalisation grotesquely undermines the hard and courageous work undertaken to end FGM worldwide. The medicalisation trend has ostensibly failed to recognise that the proposal of removing the clitoral hood and “just nicking” the vulva contradicts the WHO’s statement that there is absolutely no reason, medical, moral or aesthetic, to cut any part of these exterior organs.

There are compelling reasons why the medicalisation of FGM is fundamentally wrong.

  • The medicalisation is and would be carried out on young girls between infancy and the age of 15. Medicalisation is an attack against the sexual and psychological integrity of young girls. Many are not in a position to say no, unable to give informed consent or to effectively resist the practice.
  • Medicalisation reflects a deep-rooted inequality between the sexes and constitutes an extreme form of discrimination against women. In some communities in order to be married a female is not considered an adult and “marriageable” without undergoing FGM, which may be performed to define her gender and/or ethnic identity. In many African communities, marriage is a women’s predominate source of economic survival. The medicalisation trend reinforces and supports this lack of choice women must make in order to be accepted in their society.
  • Accepting certain types of FGM would lead to confusion for communities and health professionals. It will adversely affect the work done on raising awareness of FGM and prevention and protection of girls.
  • The risk of a well-founded fear of persecution would be seriously undermined for asylum seekers. Asylum seekers with potential claims for international protection, either for themselves or for daughters, could plausibly be denied refugee status if confusion is created on whether or not the type of FGM they would be potentially subjected to constitutes a well-founded fear of persecution.  

The medicalisation of FGM is not an appropriate response to the health risks associated with FGM. All FGM causes a variety of negative outcomes for the health and psychological well-being of women and girls. Medicalisation fails to eliminate long-term gynaecological and obstetric complications, as well as the lifelong emotional, psychological and sexual problems. It does not prevent the feelings of anxiety, betrayal, depression, low self-esteem, panic, phobia nor other psychological issues. As FGM has no proven medical benefits, as professionals who have sworn to the Hippocrates oath to do no harm, ultimately, it is unethical to contribute to the continuation of a procedure that is quite harmful and disabling for women. Medicalisation of FGM gives it an aura of normalcy, legitimacy, and acceptability. The mutilation of females is outrageous when considering that the alterations proposed are both traumatic and life-changing.

An additional concern of the medicalisation trend is the bleak message that removing a female body part for non-medical reasons is acceptable as it is just a “nick.” Who will be there to determine the measure of the “nick”? What part shall be nicked? The clitoral prepuces? The labia minora? Near the special receptacles of nerve endings that are clustered in the clitoris?  The skin of the inner surface of the labia? Is the medicalisation trend assuming that this undefined “nicking” by a chosen trained professional now is safe and correct?

The implication that it is just a nick obscures and trivializes the underlying degradation that this nick imposes on a woman and the senseless attack on women’s’ genitals for no other reason than that they are female. It reinforces the sense of inferiority on this already marginalised gender.

FGM is not open for debate without violating international law and medical ethics. As long as it is accepted in any form, FGM will thrive. Partial FGM is simply not acceptable. A nick is simply unacceptable.  The key phrase is zero tolerance.

More about Lorraine:

photo-3

Lorraine is is a British solicitor and a New York lawyer. She is currently an international law professor in the Anglo-American Law degree programme at the Universitié De Cergy where she lectures on gender law and human rights, and at the Universitié De Paris-Dauphine where she lectures on the Legal Aspects of Gender Violence. She is often an invited speaker on GBV and FGM. Recently, she was invited as a speaker to lead the medicalisation workshop at the End FGM European Network conference that was held in Paris.

 

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Trauma and Female Genital Cutting, Part 3: The Body and the Brain

(This article is Part 3 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 Joanna Vergoth, LCSW, NCPsyA

Trauma overwhelms us and disrupts our normal functioning, impacting both the brain and body, both of which interact with one another to regulate our biological states of arousal. When traumatized, we lose access to our social communication skills and displace our ability to relate/connect/interact with three basic defensive reactions: namely, we react by fighting, fleeing, or freezing (this numbing response happens when death feels imminent or escape seems impossible).   

In order to understand and appreciate our survival responses, it’s important to have a basic understanding of how our brain functions during a traumatic experience, such as undergoing Female Genital Cutting or FGC.

Our brains are structured into three main parts:

image1The human brain, which focused on survival in its primitive stages, has evolved over the millennia to develop three main parts, which all continue to function today. The earliest brain to develop was the reptilian brain, responsible for survival instincts. This was followed by the mammalian brain (Limbic system), with instincts for feelings and memory. The Cortex, the thinking part of our brain, was the final addition.

The Reptilian brain:

The reptilian brain, which includes the brain stem, is concerned with physical survival and maintenance of the body. It controls our movement and automatic functions, breathing, heart rate, circulation, hunger, reproduction and social dominance— “Will it eat me or can I eat it?” In addition to real threats, stress can also result from the fact that this ancient brain cannot differentiate between reality and imagination. Reactions of the reptilian brain are largely unconscious, automatic, and highly resistant to change.  Can you remember waking up from a nightmare, sweating and fearful—this is an example of the body reacting to an imagined threat as if it were a real one.

The Limbic System:

Also referred to as the mammalian brain, this is the second brain that evolved and is the center for emotional responsiveness, memory formation and integration, and the mechanisms to keep ourselves safe (flight, fight or freeze). It is also involved with controlling hormones and temperature. Like the reptilian brain, it operates primarily on image5a subconscious level and without a sense of time.

The basic structures of Limbic system include:  thalamus, amygdala, hippocampus and hypothalamus  

The Neocortex:

The neocortex is that part of the cerebral cortex that is the modern, most newly (“neo”) evolved part. It enables executive decision-making, thinking, planning, speech and writing and is responsible for voluntary movement.

But…image6

Almost all of the brain’s work activity is conducted at the unconscious level, completely without our knowledge. While we like to think that we are thinking, functioning people, making logical choices, in fact our neocortex is only responsible for 5-15 % of our choices.  When the processing is done and there is a decision to make or a physical act to perform, that very small job is executed by the conscious mind.

How the brain responds to Trauma

The fight or flight response system — also known as the acute stress response — is an automatic reaction to something frightening, either physically or mentally. 

This response is facilitated by the two branches of the autonomic nervous system (ANS) called the sympathetic nervous system (SNS) and parasympathetic nervous system (PNS) which work in harmony with each other, connecting the brain with various organs and muscle groups, in order to coordinate the response.

Following the perception of threat, received from the thalamus, the amygdala immediately responds to the signal of danger and the sympathetic nervous system  (SNS) is activated by the release of stress hormones that prepare the body to fight or escape.

It is the SNS which tells the heart to beat faster, the muscles to tense, the eyes to dilate and the mucous membranes to dry up—all so you can fight harder, run faster, see better and breathe easier under stressful circumstances.  As we prepare to fight for our lives, depending on our nature and the situation we are in, we may have an overwhelming need to “get out of here” or become very angry and aggressive (See ‘I underwent female genital cutting in a hospital in Rajasthan’ on Sahiyo’s blog). Usually, the effects of these hormones wear off only minutes after the threat is withdrawn or successfully dealt with.

However, when we’re terrified and feel like there is no chance for our survival or escape, the “freeze” response, activated via the parasympathetic nervous system, can occur. The same  hormones or naturally occurring pain killers that the body produces to help it relax (endorphins are the ‘feel good’ hormones) are also released into the bloodstream, in enormous amounts, when the freeze response is triggered. This can happen to people in car accidents, to sexual assault survivors and to people who are robbed at gunpoint. Sometimes these individuals pass out, or mentally remove themselves from their bodies and don’t feel the pain of the attack, and sometimes have no conscious or explicit memory of the incident afterwards. Many survivors of female genital cutting have reported fainting after being cut. Other survivors have reported blocking out their experiences of being cut (See ‘I don’t remember my khatna. But it feels like a violation’). Our bodies can also hold on to these past traumas which may be reflected not only in our body language and posture but can be the source of vague somatic complaints (headaches, back pain, abdominal discomfort, etc.) that have no organic source. FGC survivors who were cut at very young ages can be plagued with ambiguous symptoms such as these.

Neuroscientists have identified two different types of memory: explicit and implicit. The hippocampus, the seat of explicit memory, is not developed until 18 months. However, the implicit memory system, involving limbic processes, is available from birth. Many of our emotional memories are laid down before we have words or explicit recall, yet they influence our lives without our awareness. Although a traumatized person may not explicitly remember the traumatic event(s), the memory is held in the body: ‘‘What the mind forgets, the body remembers in the form of fear, pain, or physical illness’’ (Cozolino, 2006, p. 131; Van der Kolk, 1994).

The brain and PTSD

For those affected by Post Traumatic Stress Disorder — especially those who had no chance to fight back successfully or escape — the body and the brain have been blocked from responding normally and the trauma does not end.

Dr. Bessel van der Kolk (2001), a major clinician and researcher in the field of trauma notes that individuals with PTSD ‘‘are very sensitively tuned to pick up threat and respond to minor stimuli as if their life were in danger”.

What Dr Bessel is referring to is the fact that for those with PTSD, the trauma has not been able to come to a conclusion and remains unfinished. When stressors are present or familiar triggers (such as a person, place, or scent) are activated, the person can feel threatened and those fight-or-flight reactions stay turned-on, prompting the amygdala to be in a state of perpetual overactivation — in effect, hijacking the thinking process. Some FGC survivors in the Bohra community have experienced versions of such responses. For example, one young woman interviewed in the documentary A Pinch of Skin mentioned that her traumatic memories of being cut are triggered when she sees her cutter in the neighbourhood, and she ‘never wants to see that lady again’.  

When the amygdala is overactive and in control it registers only emotional and sensory information so that when the hippocampus tries to record the event sequentially it is compromised by these hormonal releases and only fragmented flashes of memory and emotional distress are remembered. This, too, is common in the way many FGC survivors remember their experience of being cut.

Why this happens

Trauma impairs the integrative functioning in the brain and neural networks get stuck in paths related to processing and encoding fear. The limbic system stores our emotional memories and replicates the response we had to the earliest time we experienced a similar situation: if we are in a state of distress we will revisit a memory of distress and that will cause more somatic sensations of distress.

PTSD reflects a condition in which the body’s natural mechanisms for recovery have failed, resulting in a prolonged state of negative stress arousal—causing increased heart rate and blood pressure, restricted flow of blood to the genitals and digestive systems—in effect making it hard to process information, eat, sleep, salivate or be sexually aroused.

For more information about the Psychosexual Consequences of trauma, see Trauma and Female Genital Cutting, Part 4: Psychosexual Consequences.

About Joanna Vergoth:

Joanna is a psychotherapist in private practice specializing in trauma. Throughout the past forma logo15 years she has become a committed activist in the cause of FGC, first as Coordinator of the Midwest Network on Female Genital Cutting, and most recently with the creation of forma, a charity organization dedicated to providing comprehensive, culturally-sensitive clinical services to women affected by FGC, and also offering psychoeducational outreach, advocacy and awareness training to hospitals, social service agencies, universities and the community at large.

Penn State Law School Host Conference on Female Genital Cutting

On April 12-13th, the Dickinson Law’s FGM Legislation Project hosted a conference, “Crafting Legislative and Medical Solutions to Address Female Genital Mutilation Locally and Internationally,” at Dickinson Law. This conference aimed to educate the public, lawyers and medical professionals about the legal, social, psychological and medical consequences of FGC. Experts and practitioners gathered to address the medical implications for women who have undergone it, the need for legislative action, and cultural competencies and prevention. Sahiyo Cofounder, Mariya Taher participated in a panel session, “Effective FGM Prevention and Survivor Advocacy.” A live stream of the event can be found here. On April 13th, a working group gathered to create and discuss an optional protocol to the Convention on the elimination of all forms of discrimination against women that focuses primarily on Female Genital Cutting.

Trauma and Female Genital Cutting, Part 2: Post Traumatic Stress Disorder

(This article is Part 2 of a seven-part series on trauma related to FGC. 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 Joanna Vergoth, LCSW, NCPsyA

Post-Traumatic Stress is the name given to a set of symptoms that persist following a traumatic incident and may be especially severe or long when the stressor has been of human design, such as in a violent personal/sexual assault (as in rape, torture, or Female Genital Cutting). These symptoms, which recreate the physical reliving of the trauma, can affect the way we think, feel and behave and, if experienced frequently, the condition that develops is called Post Traumatic Stress Disorder (PTSD).

PTSD is a complex psycho-biological condition that develops differently from person to person because everyone’s nervous system and tolerance for stress is a little different. PTSD not a mental illnessWhile you’re most likely to develop symptoms in the hours or days following a traumatic event, it can sometimes take weeks, months, or even years before they appear.

The specific symptoms of PTSD can vary widely between individuals, but generally fall into the categories described below.

Re-experiencing

Re-experiencing is the most typical symptom of PTSD and occurs when a person involuntarily and vividly re-lives the traumatic event in the form of a flashback.

Flashbacks appear as memories or fragments of memories from recent or past events and can leave you feeling fearful, confused and distressed. Jarring and disruptive, they can last a few brief seconds or involve extensive memory recall.

Below are the categories and some examples of flashbacks:

  • Visual Memories: various related images
  • Auditory Memories: sounds of breathing, doors shutting, footsteps.
  • Emotional Memories: feelings of distress, hopelessness, rage, terror or a complete lack of feelings (numbness).
  • Body Memories: physical sensations like genital pain, nausea, gagging sensation, difficulty swallowing, feeling of being held down.
  • Sensory Memories: of certain odors (e.g. perfume, body odor, alcohol) or tastes (e.g. sweat, blood).

For some women affected by Female Genital Cutting (FGC), re-traumatizing triggers can be their initial (and ongoing) sexual experiences. Not only can the physical position (identical to that required for FGC) induce a flashback, but the already traumatized genital area can feel repeatedly violated with sexual activity, gynaecological exams or childbirth itself.

Flashbacks can be accompanied by the same physiological reactions experienced at the time of the trauma, such as dizziness, rapid heartbeat, or sweating. In response to these distressing memories people can develop breathing difficulties, experience disorientation, muscle tension, pounding heart, shaking.

Hyperarousal

Trauma is stress run amuck. It dis-regulates our nervous systems and distorts our social awareness—displacing social engagement with defensive reactions. This state of mind is known as hyperarousal and often leads to:

  • Irritability; angry outbursts
  • sleeping problems; nightmares
  • difficulty concentrating

In severe cases, many have trouble working or socializing and may engage in reckless behaviors (driving too fast; being argumentative or provocative). Others with PTSD may feel chronically anxious and find it difficult to relax or concentrate. Also, problematic for many is difficulty falling or staying asleep or suffering from nightmares; feeling always anxious and on edge (referred to as hypervigilant) –they may easily be startled.

Feeling afraid is a common symptom of PTSD and having intense fear that comes on suddenly could mean you are having a panic attack. It can happen when something reminds you of your trauma, and may trigger fearing for your life or losing control.

Although anxiety is often accompanied by physical symptoms, such as a racing heart or knots in your stomach, what differentiates a panic attack from other anxiety symptoms is the intensity and duration of the symptoms. Panic attacks typically reach their peak level of intensity in 10 minutes or less and then begin to subside. 

Capture DSM PTSD

Negative emotional states

Some FGC-affected women may feel betrayed and develop problematic relationships with their mother, or female authority figures, and suffer from low self-esteem and concerns about body image. In addition, traumatized girls and women may develop persistent negative emotional states (e.g. fear, horror, anger, guilt, or shame) and engage in distorted thinking such as “I am bad,” “No one can be trusted,” “The world is completely dangerous place.”

In Sahiyo’s online survey of Dawoodi Bohra women, conducted in 2015-16, 48% of the women who had undergone FGC reported that the experience of FGC (khatna) left an emotional impact on their adult life. This impact included feelings of being haunted/traumatized by the memory of being cut, feeling betrayed and violated by the family, feelings of distrust towards them, as well as anger and fear.  

Avoidance and emotional numbing

Trying to avoid being reminded of the traumatic event is another key symptom of PTSD.

Individuals may try to block out the anxiety or fear associated with the distressing emotional feelings, by avoiding places, people and situations reminding them of the original traumatic experience. For example, the possibility of seeing the “cutter” in a social gathering may be very distressing and re trigger re-traumatization. (See A Pinch of Skin documentary by Priya Goswami).  

Some people attempt to deal with their feelings by trying not to feel anything at all. This is known as emotional numbing. PTSD diagram

Many people with PTSD try to push memories of the event out of their mind, often distracting themselves with work or hobbies. Others may engage in self-destructive behaviors (drug or alcohol abuse; eating disorders) in order to distract or numb themselves to feelings that are too painful to tolerate. Those feeling detached and numb often have trouble showing or accepting affection and, becoming isolated and withdrawn, may lose interest in people or activities they used to enjoy.

Dissociation is a mental process that causes a lack of connection in a person’s thoughts, memory and sense of identity. It is a normal reaction to trauma and can help cut off the pain, horror and terror for a person experiencing mortal danger; an attempt to be “outside” the events (outside of oneself; besides oneself) happening rather than “inside” the fearful experience. Any of us—at any age— if confronted with a life-threatening event might dissociate and out-of-body experiences, experienced during war or life-threatening disasters and medical surgeries, are well documented. The advantages of dissociating under unbearable conditions are easy to understand, but dissociative reactions can occur whereby the individual feels or acts as if the traumatic event were recurring and may confuse ordinary stress with life threatening circumstances.

PTSD can occur with or without dissociative symptoms. And, although it can occur at any age, including childhood, not every traumatized person gets full-blown PTSD, or experiences PTSD at all. PTSD is diagnosed only if the symptoms last more than a month. In those who do have PTSD, symptoms usually begin within 3 months of the trauma, and the course of the illness varies. Some people recover within 6 months, others have symptoms that last much longer. In some cases, the condition may be chronic. Sometimes, memories of the traumatic event and any accompanying PTSD symptoms don’t appear until years after the actual experience.

PTSD in children

PTSD can affect children as well as adults. It can also result from surgery performed on children too young to fully understand what’s happening to them.

Children with PTSD can have similar symptoms to adults, such as having trouble sleeping and upsetting nightmares.

Like adults, children with PTSD may also lose interest in activities they used to enjoy and may have physical symptoms such as headaches and stomach aches.

However, there are some symptoms that are more specific to children with PTSD, such as:

  • bedwetting
  • being unusually anxious about being separated from a parent or other adult
  • re-enacting the traumatic event(s) through their play

For more information about how the brain and body process trauma, watch out for Trauma and Female Genital Cutting, Part 3 — Trauma: the Body and the Brain.

About Joanna Vergoth: 

Joanna is a psychotherapist in private practice specializing in trauma. forma logoThroughout the past 15 years she has become a committed activist in the cause of FGC, first as Coordinator of the Midwest Network on Female Genital Cutting, and most recently with the creation of forma, a charity organization dedicated to providing comprehensive, culturally-sensitive clinical services to women affected by FGC, and also offering psycho-educational outreach, advocacy and awareness training to hospitals, social service agencies, universities and the community at large. 

Trauma and Female Genital Cutting, Part 1: What is trauma?

(This article is Part one of a seven-part series on trauma related to FGC. This article should not be used in lieu of seeking professional mental health and counseling services when needed)

By Joanna Vergoth, LCSW, NCPsyA

Many women who have undergone FGC may not have any lasting disturbances. But based on the Sahiyo study alone (see pie-chart below), there are those who may benefit from a deeper understanding of the effects of trauma. Often, we minimize, dismiss or normalize our symptoms and resign ourselves to feeling/living compromised. Learning more about trauma can provoke conversation; help one to feel less isolated and can prompt one to seek professional help. 

What is trauma?     

A traumatic event is defined as direct or indirect exposure to actual or threatened death, serious injury or sexual violence. The incident may be something that threatens the person’s life or safety, or the life of someone close to the victim. Traumatic incidents can include kidnapping, serious accidents such as car or train wrecks, natural disasters such as floods or earthquakes, or violent attacks such as rape, sexual or physical abuse, or FGC. As defined—although culturally sanctioned— FGC is a traumatic event (see chart from Sahiyo’s study to the right).Q25a

Although for some the consequences can be minimal, most of the evidence suggests that FGC is extremely traumatic and the physical or medical complications associated with FGC may remain acute or chronic. Early, life-threatening risks include hemorrhage, shock secondary to blood loss or pain, local infection and failure to heal, septicemia, tetanus, trauma to adjacent structures, and urinary retention. One of the more frequent longer-term medical consequences includes adhesions or scarring, which can contribute to lingering pain and impede sexual functioning.

The focus of FGC has long been regarded from a physical and medical perspective but it is equally important to consider the psychological and emotional implications of this practice.  It has been reported that the psychological trauma that women experience through FGM ‘often stays with them for the rest of their lives’ (Equality Now and City University London, 2014, p.8). Sahiyo’s study found that of the 309 participants in the Q25study who had undergone FGC in the Dawoodi Bohra community, almost half (48%) reported that the practice left a negative emotional impact on their adult life.

Usually, the girl, unprepared for what is about to happen, is taken by surprise and cannot prevent what is about to occur. Those that can remember the ‘day they were cut’ often report having initially felt intense fear, confusion, helplessness, pain, horror, terror, humiliation, and betrayal. Many have suffered a multi-phase trauma; the first being forced down and cut and then second is seeing or hearing another family member endure the procedure. Even anticipating the procedure, oneself can be terrifying. Also of significance is the community and family reaction to the painful reactions experienced by these young women. Often girls can be chided for crying and not being brave while undergoing the cutting. This dismissive, non-nurturing reaction can potentially lead to another facet of the multi-phase trauma.   

Some proponents of FGC actually consider that the shock and trauma of the surgery may contribute to the behavior described as calmer and docile—considered to be positive feminine traits.

FGC is a traumatic event that can profoundly rupture an individual’s sense of self, safety, ability to trust and feel connected to others—aspects of life considered fundamental to well-being. Such genital violence can interrupt the process of developing positive self-esteem. And, when children are violated their boundaries are ruptured leading to feelings of powerlessness and loss of control. Children who have experienced trauma often have difficulty identifying, expressing and managing emotions, and may have limited language for describing their feelings and as a result, they may experience significant depression, anxiety or anger.   

Over time, if the distress can be communicated to people who care about the traumatized individual and these caretakers respond adequately, most people can recover from the traumatic event. But, some FGC affected girls and women experience severe distress for months or even years later.   

The symptoms of trauma:

Outlined below are some of the consequences that may occur following a traumatic event. Sometimes these responses can be delayed, for months or even years after the event. Often, people do not even initially associate their symptoms with the precipitating trauma.  

Physical 

  • Eating disturbances (more or less than usual) 
  • Sleep disturbances (more or less than usual) 
  • Sexual dysfunction 
  • Low energy 
  • Chronic, unexplained pain

Emotional/behavioral

  • Depression, spontaneous crying, despair, and hopelessness 
  • Anxiety; feeling out of control 
  • Panic attacks 
  • Fearfulness 
  • Feelings of ineffectiveness, shame, despair, hopelessness 
  • Irritability, anger, and resentment 
  • Emotional numbness 
  • Withdrawal from normal routine and relationships
  • Feeling frequently threatened
  • Feeling damaged 
  • Self-destructive and impulsive behaviors
  • Sexual problems 

Cognitive 

  • Memory lapses, especially about the trauma 
  • Difficulty making decisions 
  • Loss of previously sustained beliefs
  • Decreased ability to concentrate 
  • Feeling distracted

Over time, even without professional treatment, traumatic symptoms generally subside, and normal daily functioning gradually returns. However, even after time has passed, sometimes the symptoms don’t go away. Or they may appear to be gone, but surface again in another stressful situation. When a person’s daily life functioning or life choices continue to be affected, a post-traumatic stress disorder (PTSD) may be the problem, requiring professional assistance.

To learn more about PTSD, see our Part II – Post Traumatic Stress Disorder

About the Author:

Joanna Vergoth is a psychotherapist in private practice specializing in trauma. forma logoThroughout the past 15 years she has become a committed activist in the cause of FGC, first as Coordinator of the Midwest Network on Female Genital Cutting, and most recently with the creation of forma, a charity organization dedicated to providing comprehensive, culturally-sensitive clinical services to women affected by FGC, and also offering psychoeducational outreach, advocacy and awareness training to hospitals, social service agencies, universities and the community at large.