Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.) Chapter 30: Female Circumcision (introduction...) Types of female circumcision Health problems caused by female circumcision What to do for health problems Heavy bleeding and shock Infection Urine problems Problems with monthly bleeding Problems with sexual relations and sexual health Problems with childbirth Leaking urine and stool Infertility Mental health problems Working for change (introduction...) Female circumcision, human rights, and the law

Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.)

Chapter 30: Female Circumcision

This chapter was written by women who are living and working in communities where female circumcision is practiced.

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Throughout history, customs harmful to women's health have been practiced in order to make women seem more attractive or likely to marry. For example, in some European communities, a woman was thought to be more beautiful if she had a very small waist. So starting when they were girls, women were forced to wear a band of stiff cloth called a 'corset' tied so tightly around the waist and hips it sometimes broke their rib bones, and kept them from breathing or eating properly. It was very difficult for them to do anything but sit still or walk slowly.

And in parts of China, a woman had higher status if she had very tiny feet. So the bones of some girls' feet were broken and their feet tightly wrapped in cloth so that when they became women, their feet were deformed and they were unable to do more than walk slowly.

¨ Sometimes this practice is called excision.

These customs have been stopped, but in some parts of the world, other customs continue. Female circumcision is one them. It is practiced in many communities of Africa, in some communities in the Middle East, and in a small number of communities in Southeast Asia. It involves cutting part of a girl's or woman's genitals. Female circumcision is practiced for a variety of reasons, most of them based on culture and tradition. It is often a cause for great celebration in the community.

¨ In some communities, a girl must be circumcised before she can become a wife and mother and, in some cases, to own property.

Female circumcision does not stop a woman's need for love and companionship or affect her moral behavior. But it does interfere with her normal body functions, and can harm her relationship with her husband or partner. Circumcision also causes many health problems, and some of these problems can lead to lasting harm or death.

Types of female circumcision

There are 3 types of female circumcision:

1. The clitoris is partly or completely removed.

2. The clitoris is removed along with the small skin folds of the outer genitals.

3. The outside genitals are cut away, and the opening to the vagina is sewn almost closed. This is called 'infibulation'. A small hole is left for urine and monthly bleeding to flow out. This type of circumcision is the most dangerous and causes the most serious health problems. But all types of female circumcision can cause bleeding, infection and death.

The way that a girl is cut is different in different places, but it is almost always done as part of a ceremony in which a girl moves from childhood into adulthood.

Health problems caused by female circumcision

These problems may happen right away, or in the first week:

· heavy bleeding
· infection
· shock from severe pain, bleeding, or infection
· problems with passing urine

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All these problems are extremely dangerous. Get help right away.

These problems may happen later, and can last for many years:

· problems with monthly bleeding
· problems with sex
· problems during and after childbirth
· leaking urine and stool
· being unable to get pregnant (infertility)
· lasting pain
· mental health problems

What to do for health problems

Heavy bleeding and shock

Heavy bleeding from a deep cut or tear can happen quickly and is very dangerous. If a girl loses too much blood, she can go into shock and die.

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Warning signs of shock (one or more of the following):

· severe thirst
· pale, cold, and damp skin
· weak and fast pulse (more than 110 beats per minute)
· fast breathing (more than 30 breaths per minute)
· confusion or loss of consciousness (fainting)

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What to do:

· Get help immediately. Shock is an emergency.

· Press firmly on the bleeding spot right away. Use a clean, small cloth that will not soak up a lot of blood. Keep her lying down while you take her to get medical help.

· Help her drink as much as she can.

· If she is unconscious and you live far from health services, you may need to give her rectal fluids before taking her for help.

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Infection

If the cutting tool is not cleaned properly (disinfected) before and after each use, germs can cause a wound infection, tetanus, HIV/AIDS, or hepatitis.

¨ Signs of infection can begin any time during the first 2 weeks after the circumcision

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Signs:

· of wound infection: fever, swelling in the genitals, pus or a bad smell from the wound, pain that gets worse.

· of tetanus: tight jaw, stiff neck and body muscles, difficulty swallowing and convulsions.

· of shock (see the list above).

· of an infection in the blood (sepsis): fever and other signs of infection, confusion and shock.

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For signs of HIV/AIDS or hepatitis, see the chapters on "AIDS", and "Sexually Transmitted Diseases and Other Infections of the Genitals".

IMPORTANT
If a girl begins to show signs of tetanus, shock, or sepsis, take her for medical help right away.

What to do for infection:

· Give an antibiotic, such as amoxicillin or erythromycin.

· Keep watching for warning signs of tetanus, sepsis, and shock. If she has not yet had a tetanus vaccination, she should get one immediately.

· Give modern or plant medicines for pain.

· Keep the genitals very clean. Wash them with water that has been boiled and cooled and has a little salt in it.

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Cutting is even more dangerous for girls who have not had a tetanus vaccination. All girls should be vaccinated.

Urine problems

Since circumcision often causes severe pain when a girl passes urine, some girls try to hold their urine back. This can cause infection and damage to the urine tubes, bladder, and kidneys. Holding back urine frequently can cause stones to form in the bladder.

What to do:

· Run clean water over the genitals when passing urine. This makes the urine less acid, so it causes less pain. Drinking more liquids will also help.

· Pour water into a bucket or pan. The sound of the running water sometimes helps the person start to pass urine.

· Apply a damp towel soaked in warm water to the genitals. This may help relieve the pain.

· Watch for signs of bladder and kidney infection.

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If a girl has not been able to pass urine for more than a day or night, and her lower belly feels tight and full over the bladder, it is an emergency. She must see a trained health worker immediately who can put a tube in the bladder to drain the urine. Do not give her more liquid to drink, because this will add pressure on her bladder and kidneys.

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Problems with monthly bleeding

If the vaginal hole that is left after infibulation is too small, or if it is blocked by scarring inside the body, the flow of a girl's monthly bleeding can be blocked. This can cause:

· very painful monthly bleeding.

· long monthly bleeding, lasting 10 to 15 days.

· no monthly bleeding because the vaginal opening is blocked and the blood cannot get out.

· trapped blood that can lead to serious pelvic inflammatory disease (PID) and scarring in the womb and tubes. This can cause infertility.

What to do:

· Apply a towel soaked in hot water to the lower abdomen to relieve pain. (Be careful not to burn the skin.)

· It may help to walk around and do light work or exercise.

If the problems are severe, the vaginal opening may need to be made larger. This should be done by a skilled health worker to prevent harm to the reproductive parts inside.

Problems with sexual relations and sexual health

If a circumcised woman has none of the health problems described in this chapter, she may be able to enjoy sex. But many women who have been circumcised, especially those who have been infibulated, find sex difficult.

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In some communities, young women are circumcised and married on the same day. Or a woman who was circumcised at a young age may have her vaginal opening made larger just before first sex in marriage. If she is expected to have sex before the wound has healed, sex will be very painful and dangerous, and the wound may take longer to heal. Open wounds also increase her risk of catching HIV/AIDS or sexually transmitted diseases (STDs).

¨ All wounds must be completely healed before having sex.

During sex, a woman may find it difficult to become aroused, since the clitoris has been cut off.

If you live where infibulation is practiced, help men to understand that the vaginal opening should be safely and gently made larger. Opening should be done long before the first time a woman has sex, to allow time for complete healing. Opening should be done by a health worker who uses properly cleaned cutting tools, and who cares for the wound afterward to prevent infection.

¨ If you can encourage married couples to talk to one another, it will be easier for them to talk about how circumcision affects their sexual relations.

What to do for problems with sex:

A woman can talk with her partner about finding ways to become more sexually aroused, and explain that she may need more time to feel aroused.

She can also talk about ways to make sex less painful. Having enough wetness (lubrication) can make sex safer and hurt less.

Getting reproductive health care If an infibulated woman's vaginal opening is not large enough, she cannot get a pelvic exam or a Pop test for cancer. This means she has fewer choices for protecting herself against pregnancy, cancer, and STDs.

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Problems with childbirth

¨ Blocked births are more common in young girls whose bodies are not fully grown.

With some types of circumcision, there is a greater risk that the baby will have difficulty getting out of the vagina (blocked birth). If the hole left after infibulation is very small, it must be opened so the baby's head can pass through. This is called 'deinfibulation' (see the box). If the person who does the opening is not skilled, it can cause other complications.

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¨ If a woman lives far from emergency services, having a baby at home may be dangerous - especially if she has been infibulated.

Scarring from circumcision can also cause the genitals to tear more during childbirth, since scarred skin does not stretch easily. Heavy bleeding may result.

¨ Some traditional midwives have had special training for helping circumcised women have safe births, and for problems from infibulation.

What to do:

Plan in advance for childbirth. During the second half of pregnancy, a pregnant woman should try to see a trained midwife or other health worker trained in helping circumcised women give birth. The midwife can tell her if there is a risk of complications, or if the vaginal opening should be made larger. If there are risks, a woman can make plans for getting medical care ahead of time.

Emergency: If an infibulated girl or woman is giving birth and the baby will not come out (a blocked birth) the scars must be cut so the baby can be born. If possible, this should be done by a trained health worker. But if there is no health worker nearby, wash your hands well with soap and clean water before you begin, and wear clean rubber or plastic gloves or bags on your hands. The cutting tool must be cleaned and disinfected first. If you have to cut someone, get her to a health worker who knows how to repair the cut right after the birth. Figure To cut the scars open (deinfibulation): 1. Put 1 or 2 fingers under the band of scar tissue. 2. Inject local anesthesia if you know how. 3. Cut the old scar open by snipping the bands of scar tissue until you can see the woman's urine hole. The vagina will probably now stretch enough to let the baby come out. 4. After birth the opening will need repair. This might be a good time to explain to the woman or girl that it would be safer not to be infibulated again - it will cause more scarring and can block the urine tube and vagina. A trained health worker can repair the genitals without closing the opening. 5. To prevent infection, give antibiotics: amoxicillin, 3 grams all at once, or erythromycin, 500 mg 4 times a day for 7 days.

Leaking urine and stool

During a blocked birth, the lining of the vagina, bladder or rectum can tear, causing urine or stool to leak out of the vagina.

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If a couple has and sex because the woman's vaginal opening is too small, the anus may become stretched or torn. Stool may leak out of the anus.

Leaking urine and stool are terrible problems to live with. Many young women have been rejected by their partners because of the smell and because they cannot control the leaking. Seek medical help as soon as the problem is discovered.

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Infertility

Infection can cause scarring of the womb and tubes, which make it difficult for a woman to get pregnant. If you think there may be an infection caused by a sexually transmitted disease, see the chapter on "STDs and Other Infections of the Genitals". If you think there are problems with scarring in the womb or tubes from blocked flow of monthly bleeding, see a trained health worker about making the opening larger.

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Mental health problems

A girl who has been circumcised can become overwhelmed with fear, worry (anxiety), or sadness. When circumcision is done in front of women that a girl knows and trusts to protect her from harm, she may feel that she can no longer trust anyone. It is worse if the girl did not wish to be circumcised.

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Chronic pain and suffering can cause other lasting mental health problems, such as deep sadness (depression), and feelings of helplessness and worthlessness. Sexual problems can also cause severe strain between a woman and her partner. A woman may feel she is unable to please him because the pain makes her afraid of sex.

What to do:

· Encourage her to talk about her feelings.
· If she seems withdrawn, distant, and unable to do daily activities.

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Working for change

If you are not sure how you feel about female circumcision, weigh the risks to help you decide. Are the benefits of being circumcised worth the health problems? Culture is always changing to meet new community needs. Can this practice also be changed?

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What you can do:

If you do not agree with this practice, there are many ways you can help girls in your community:

· If you are a mother, help your daughters feel valued and loved, whether they are circumcised or not.

· Encourage your daughters to continue with their education and to learn enough to make their own decisions about their lives and their futures. Every child has a right to good health and an education.

· Share the information about the health problems caused by female circumcision with other women and men in your community. Work with them for change.

· Find out what women's organizations in your community or region are doing.

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· If you are a health worker who does circumcisions, explain the risks to those who ask you.

· Get training on what to do for health problems of female circumcision.

· Work for change with traditional and religious leaders. Religion does not support female circumcision, but this has not been well understood. Try to discuss this with your religious leaders.

¨ For real change to happen in your community, people must work together to end this harmful practice.

· Find ways to discourage circumcision ceremonies in your community. Find other rituals that can mark a girl's passage from childhood to adulthood. These rituals could include prayers to the ancestors, or sacrifices that are not harmful to women. In many places there are coming-of-age rituals for girls that do not harm their health.

· Recognize the important role traditional birth attendants (TBAs) play in the health of the community. Since TBAs often perform circumcision, they need to be trained about its harmful effects. Find ways to replace the gifts they are given after circumcision ceremonies, and look for other ways their help is needed in the community. If other rituals are used to replace circumcision, include TBAs as an important part of the giving and receiving of any gifts.

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Female circumcision, human rights, and the law

This chapter has mainly described the health problems that female circumcision often causes. But even if no health problems occur, a circumcised girl has still been harmed and her human rights to bodily integrity, safety, and health have been violated in the name of tradition. Many believe that circumcision also violates the right to privacy and choice because it is done mainly to girl children who are not old enough to agree to the practice. Some groups are calling for new laws to make female circumcision illegal and punish those who practice it. These laws need to be written carefully so that in communities where circumcision is practiced, it will not continue in secrecy, which would be even more dangerous. Also, girls and women who have been circumcised should not feel afraid to seek medical help if they have problems.