What can be done ?
To be able to combat the increasing medicalization of FGM, it is first necessary to understand why health personnel agree to perform such an act … (1, 2)
- They belong to a community that practices FGM and it is in line with their beliefs, or they feel it is their duty to support a patient’s request for FGM when they have a socio-cultural motivation.
- They consider medicalization to be a “lesser evil” and to reduce risks and complications.
- They consider FGM to be harmless and even medically indicated.
- They are first attracted by financial gain.
So how can we act?
Better training of health professionals is necessary to deconstruct their beliefs and make them aware of the harmful consequences of the practice. The lack of knowledge about FGM and its consequences, as well as the cultural and social implications behind the practice (control of girl’s and women’s sexuality and freedom), make it easier for health professionals to accept the practice.
Members also agreed with this. The training of health professionals has been part of Plan International’s strategy in Mali.
“We organized workshops in order to provide:
- Training and awareness-raising on FGM, bringing together 80 NGO workers and health workers from the project intervention zones, which made it possible, in particular, to identify all the terms used to designate FGM and also the genital organs, in local languages,
- Tips on the management of the complications of excision, bringing together representatives and agents of partner NGOs. The main speaker at this second workshop was Dr. Moustapha Touré who, for the first time, presented a selection of photos of the complications he was facing, and explained their medical and psychological management, as well as the often very complicated follow-up. »
Dr. Hashim Hounkpatin highlighted five key points to improve knowledge about FGM, deconstruct the myths surrounding FGM and its medicalization, and give more importance to women’s health and freedom of choice:
- “Good sex education will enable women/girls (and boys too) to have a more responsible sexuality and not succumb to the lure of the forbidden. Sex education rather than FGM would allow girls/women to remain virgins if they so desire. The ultimate decision rests with them.
- We know that FGM is more in line with social norms than religious ones. We need to involve not only religious but also social leaders to help deconstruct certain beliefs that our populations repeat mechanically because they are consecrated by tradition and are not questioned. (rite of passage, fear of social sanctions,…)
- FGM is a social practice to subjugate women. Does it make the women more faithful?
- FGM does not facilitate childbirth and does not reduce infant mortality.
- Medicalization does not reduce the importance of the operation (re-cutting in the community). It violates the first principle of medical ethics (do no harm), violates the rights of women and girls, does not prevent the long-term consequences and could legitimize FGM. »
Giving a clear framework to health professionals contributes to their awareness and to the clear qualification of the practice of FGM as well as its potential medicalization.
- A political framework: political will mobilized for the abandonment of the practice and a clear position of the Ministry of Health condemning medicalization.
- A legal framework: medicalization must be explicitly and/or clearly condemned by laws prohibiting FGM and the health professionals practicing it must be brought to justice. (Roseline N’Da Safié gave the example of the Ivorian law doubling the penalty initially foreseen when FGM is practiced by a member of the medical profession.)
Eva Komba also suggested improving the prosecution of health professionals, hospitals and clinics practicing FGM, giving the example of Kenya where she works:
“Where I work you find two groups of people – The elite, i.e. those who are highly aware and continue to practice FGM, for instance my neighbour, a college lecturer, had his girls cut and this shocked everyone in 2004, the rationale behind it being he still respects his culture. The second group is members of the community who have very low levels of education and are poor and use the practice to access cattle and land. The elite usually identify someone from their community like a nurse and secretly take the girls to be cut. They pay for the operation.
One of the best ways to handle medicalisation of FGM is to have the medics arrested and prosecuted, licenses of clinics and hospitals revoked and continue to keep the conversation alive in communities. Nurses and doctors should be sensitized and warned.”
Health protocols and guidelines on FGM, including the role of professional medical organizations must be put in place.
A Senegalese member raised the idea of creating awareness-raising and training tools promoting an integrated approach (human rights – health – economics) and increasing discussions in universities. They noted that medical students lacked information and knowledge about FGM and its consequences.
Strengthening the inclusion of the medical profession in prevention programmes run by NGOs would increase their knowledge and action against FGM. Indeed, health professionals can be particularly powerful and influential agents of change.
Associations should report on issues related to the local practice of medicalization and involve health professionals in programme development and implementation. Health professionals need to be made aware of the important preventive role they can play in their communities.
Fatma Soueid Ahmed shared the example of Mauritania, where collaboration with the medical profession has been established and whose participation and advocacy have been very useful in the fight against FGM and its deligitimation.
Indeed, they benefit from the confidence of the communities that listen to them. Their voices and their stories on how FGM is harmful to the health of girls and women can be powerful tools for advocacy and awareness raising.
“The harm inflicted by the practice is a compelling reason for abandoning FGM and also serves as an argument for religious leaders to decide whether or not to ban FGM. Here in Mauritania, in order to obtain the adherence of the imams through a fatwa we first had to have the declaration of the doctors in order to demonstrate that the practice harms the health of girls and women and they risk losing their lives, which is strictly forbidden by religion.
In addition, an alliance with midwives and a great deal of work with health providers was carried out and they even became the guarantors and actors in this fight against FGM. Indeed, health personnel are very much listened to and their advice is enough to make people aware of the dangers of FGM. It should also be noted that health personnel can testify without shame about cases treated following complications of FGM. In the course of their work, several medical personnel have unfortunately seen innocent victims die, without being able to help them because they arrived too late at the health centres. »
Public declarations of abandonment and/or condemnation of FGM by health professionals can be particularly effective and influential.
Stéphanka, a sociologist, gave the example of a national forum organized by local NGOs and Plan International in Mali:
“The main managers of the gynaecological-obstetrics and urology services in Bamako, as well as representatives of health professionals’ associations were invited (including midwives), there was a public affirmation of the position of these health professionals against FGM. This affirmation, together with the combined efforts of NGOs fighting against FGM and the favourable will of the government of the time, made it possible to adopt the law prohibiting FGM in hospitals. »
According to the recommendations of UNFPA, UNICEF and WHO, a holistic approach is needed to combat medicalization. Thus, they propose eight interventions:
- Legal framework, adherence to the code of conduct, sanctions and advocacy for law enforcement
- Integration of female genital mutilation and related ethical principles into medical, nursing and obstetric education
- Treatment and prevention of FGM integrated into service delivery (e.g., deliveries, antenatal and postnatal care and immunization campaigns)
- Engaging national human rights institutions and CSOs to strengthen social accountability
- Create a framework for health care providers advocating for an end to the medicalization of FGM
- Monitoring mechanisms and data collection for better policy and program development
- Establish partnerships, engage health professional associations/organizations and link with other services (e.g., social and community services) for referrals and cross-referrals
- Strengthening communities for the abandonment of FGM
This strategy implies complicity between the different protagonists, namely political decision-makers, judicial and religious authorities, training institutions for health care personnel, health professionals, civil society and the community.
Thus, it is important to work better with religious leaders and other community actors by including them in the struggle and informing them. Indeed, no complete abandonment of FGM will be possible without the support of the entire community.
In this sense, Dr. Hahim Hounkpatin suggested the following:
Continue to engage communities in discussions around their beliefs on FGM/C to address the general reasons why families desire FGM/C both within and outside the context of medicalisation.
Educate communities about the role of health care providers in promoting health and doing no harm, so that they might better understand and support their decisions not to perform FGM/C.
Kaba, a native of Guinea, stressed the importance of working with religious and traditional leaders to deconstruct the beliefs surrounding FGM and to fight against the social norm it constitutes.
“Here in Guinea, the two main reasons for the persistence of the practice remain religion and tradition (the issue of social norms in particular). Today, a great deal of progress is being made in Guinea thanks to the synergy of the different actors in the interventions. Nationally renowned religious leaders and traditional communicators have become advocates for the abandonment of FGM/C and are now conveying a strong messages to promote this abandonment. »
Finally, Dr. Souleymane Kabore recalled the importance of having studies and data on medicalization in order to fight against this practice in the most appropriate way and give visibility to the phenomenon and push governments to act:
“Thus, to fight against medicalization in Burkina Faso and in other countries of Sub-Saharan Africa, I think we must first document the phenomenon and show that it exists. In fact, medicalization is very little known here, we don’t talk about it at all. It seems that it is practised clandestinely. Next, guidelines and tools must be developed for training and raising awareness of health personnel on the problem. »
« The Community of Practice on Female Genital Mutilation » is part of the « Building Bridges between Africa and Europe to tackle FGM » project, supported by the « UNFPA-UNICEF Joint Programme on the Elimination of FGM ».
The project is coordinated by AIDOS in partnership with GAMS Belgium.
The views expressed on this website are those of the authors and do not necessarily reflect the official policy or position of the UNFPA, UNICEF or any other agency or organization.
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