The three feminine pains in Somaliland

Andrea Solnes Miltenburg

 

 

Introduction 

The practice of female genital mutilation (FGM) is still common in 28 African countries. The way of performing the practice, the age at which the practice takes place and the reasons to perform the practice differ widely. Similarities are often seen within certain ethnic groups rather than within countries. For example, people from Somali origin, mostly refugees from the civil wars in the Horn of Africa, live in many countries and generally perform the same practice. Last year I spent three months in the Edna Adan Maternity and Teaching Hospital (EAMTH) in Hargeisa, the capital city of Somaliland. Here I investigated the decision making process of women to continue the practice of FGM.

 

Terminology and epidemiology 

 

FGM is a common traditional practice amongst Somali people. In Somaliland the number of women who are subjected to FGM is one of the highest in the world. The estimated prevalence is 98%. FGM can be divided into different types. Type III of this classification involves cutting off of all external genitalia and narrowing the vaginal opening, also referred to as infibulation, which historically has been most common in the Horn of Africa. Among the women in Somaliland 90% undergo type III FGM.

Female genital mutilation (FGM), female genital cutting (FGC) and female circumcision all refer to the same practice involving total or partial removal of the external genitalia for non medical reasons. Other terms frequently used are sunna and pharaonic. Pharaonic  means infibulation and sunna refers to the symbolic pricking of the clitoral hood described by the Prophet Mohamed.

 

 

Consequences of FGM

 

The cutting

Short-term consequences include severe pain, excessive bleeding, shock and damage to other organs like the urethra, anal sphincter or glands. In rural areas and during war the conditions under which FGM is performed are appalling. The cutting is unsterile often without anaesthetics. Some women reported that the stitching was done with thorns from trees. The unsterile conditions can cause tetanus, septicaemia and even HIV and hepatitis B have been reported.

 

I was eight years old and it was horrible. My mother called an old woman. She used a thorn for suturing, because in the refugee camp there were no sutures and no needles . – 28 year old woman at EAMTH

 

After the procedure has been done, the legs of girls are bound together for several days. Due to fear of pain and opening of the stitches the girls have trouble passing urine, which may last for several days resulting in urine retention. 

The long-term consequences are related to the extend of the procedure.  In case of infibulation severe dysmenorrhoea occurs often, due to lack of space for menstrual blood flow. Urination takes a long time and often some urine is left behind the scar tissue, resulting in urine tract infections and sometimes kidney problems and bladder stones. Cyst formation and keloid are not uncommon. 

 

I used to have a lot of pain during my periods. The area was closed off so there was no place for the blood to come through. I visited a lot of doctors who said they had to open me up, but that would be too shameful.  – 28 year old woman at EAMTH

 

Few scientific data on the sexual and psychological effects are available. Some studies have shown fear of sexual intercourse, post-traumatic stress disorder, anxiety, depression and memory loss.

 

The marriage

During the wedding night the husband finds that the women is still intact. Either the same night or the morning after she will be opened so they can have intercourse. Many women explain they were scared of this moment but also feel relieved of being opened.

 

The first wedding night my husband saw I was closed and he couldn’t enter. So the next day he took me to a doctor. A place that has been opened up and is still healing that has to engage in other activities is very painful.  - 35 year old woman at EAMTH

 

The delivery

Recent studies show that FGM complicates deliveries. There is a significantly higher risk of episiotomy, prolonged labour, caesarean section and post-partum haemorrhage. The mechanisms that cause adverse obstetric outcome are not entirely clear. Scar tissue might cause obstruction, tears easily and requires episiotomy.

 

The three feminine pains

During the life of a Somali woman, she will undergo the three feminine pains as described above: circumcision, wedding and labour. In my interviews women described these life events vividly. Despite their experiences they still want to perform the practice of FGM on their daughters. In general women confirmed that it is their own decision, but they do consult their husbands and other relatives. Below I will give a brief overview of their considerations to continue with FGM.

Religion

FGM can be found in all religious groups and religion is one of the most important arguments for performing the practice. There are religious texts that might refer to female circumcision, particularly the sunna , but none of the holy texts prescribe FGM.

 

On the radio and from others I hear that prophet Mohamed says it is good to cut small.  - 26 year old woman at EAMTH

 

Almost all women chose to perform sunna on their daughters and condemned infibulations. In practice sunna can be a variety of operations, from a simple prick in the clitoral hood to extensive cutting and stitching. 

Society

Besides religion, society plays an important role in the consideration to continue FGM. This is best explained by the comments of these women:

If not circumcised a girl will be insulted that she has a big clitoris; that she is dirty. She won’t get married.  - 25 year old woman at EAMTH

If they go to their husbands house he will know, and thus the family will know. Society makes it difficult for girls to marry if they have not been circumcised.  – 25 year old woman at EAMTH

 

In literature it is widely mentioned that FGM is a perquisite for marriage, ultimately meaning that when not circumcised there would be no access to a certain status in the community. Since women play an important role in labour and secure the future by delivering children, marriage is essential. While in rural areas this might still be the case, in  cities  younger generations of both men and women are not so strict with this tradition. More important is the fear of judgment and stigmatization by peers when uncircumcised. 

Health

Uncircumcised girls are considered dirty and foul smelling. Also the genitals are thought to grow to unseemly proportions. Performing FGM will make the genitals look smooth and beautiful, as mentioned by many of the women. Still, the argument of health can also be given as a reason to avoid FGM, especially type III. The increased knowledge about the health complications related to type III FGM or infibulation, is the main reason for many women to choose for the sunna  variant. They do not want their daughters to have the same problems they had. 

Conclusion

During previous decades much has been done to eradicate FGM. Still, most women in Somaliland have undergone the practice, and now all efforts are aimed at educating young women and preventing them from performing the practice on their own daughters. Nevertheless, this is a challenge facing many obstacles.

 

 

About the author

Andrea Solnes Miltenburg is a fourth year medical student from Amsterdam who spent three months in Somaliland in 2009.

Further reading

• WHO, 2008, Eliminating Female Genital Mutilation, An interagency statement.
• World Bank & UNFPA, 2004, Female genital cutting/mutilation in Somalia, a progress report.
• Book: Cutting the rose: Female Genital Mutilation: The Practice & Its Prevention. By Efua Dorkenoo.

References

1. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. The Lancet 2006:June;367(9525)1835-1841. 
2. Creel L, Ashford L, Carr D, Roudi J, Yinger N. Abandoning Female Genital Cutting: Prevalence, Attitudes, and Effortd to End the Practice. Washington. DC: population reference bureau; 2001 
3. Shell-Duncan B. The medicalization of female ‘circumcision’: harm reduction or promotion of a dangerous practice? Social science & medicine 2001;52:1013 - 1028

 

Illustration © by Robert Oomen, all rights reserved.
Photo © by Amfion Fotoshoots (Antonette de Groot-Klootwijk), photos for Global Medicine only, all rights reserved.