Violated rights: are female genital mutilations a still existing form of violence?

Franca Di Nuovo1, Maria Riglia2, Annalisa Alberti2, Elisa Roncaglia2, Anne Destrebecq3, Monica Onorati1

1ASST Rhodense, Garbagnate Milanese, Milan, Italy; 2Degree Course in Nursing, University of Milan and ASST Rhodense, Garbagnate Milanese, Milan, Italy; 3Degree Course in Nursing, University of Milan, Italy

Received 1 June 2020; accepted 15 October 2020

Summary. Female genital mutilation is a brutal practice that violates women’s rights, by subjecting them to a real form of physical and psychological ‘torture’, as declined in the Universal Declaration of Human Rights. It is a devastating health issue, based on the pretext of social and religious convictions, as well as deeply rooted cultural beliefs. It’s an issue that affects over 200 million women and girls, who have suffered from and who must live with the effects of this practice; in addition, every year about 3.6 million girls could be subjected to mutilation of the external genitalia. This mutilating practice to which women and girls are subjected against their will, is an insult to their dignity and health. Our research is based on a review of selected articles published from 2009 to 2019, through the consultation of the PubMed and Cochrane Library databases, with keywords linked with Boolean operator AND. Recently published data show that this practice is still being exerted, despite national and international laws recognize female genital mutilation as a crime worldwide. Female genital mutilations are more frequently practiced in Africa but, due to the migratory flows, this phenomenon has also spread to other Countries, such as Europe, America and Australia. The elimination of these mutilating practices can only take place through the socio-cultural progress of the people who still downplay these practices and of the women involved. An appropriate level of education is essential in order to improve gender relations and to accelerate the social progress that could encourage to eradicate this inhuman mutilation.

Key words. Female genital mutilation, female circumcision, deinfibulation, violence, gender, rights.

Diritti violati: le mutilazioni genitali femminili sono una forma di violenza ancora attuale?

Sommario. Le mutilazioni genitali femminili rappresentano una pratica orrenda e cruenta, ancora attuale, che viola i diritti delle donne, sottoponendole a una vera e propria forma di ‘tortura’ fisica e psicologica, come declinato nella Dichiarazione Universale dei Diritti Umani. Costituisce un problema di salute devastante, che riguarda circa 200 milioni di donne e ragazze che hanno subito e che convivono con gli effetti di questa pratica; inoltre, ogni anno circa 3,6 milioni di ragazze e bambine potrebbero essere sottoposte alla mutilazione dei genitali esterni. Tale pratica mutilante si fonda sul pretesto di errate convinzioni sociali e religiose e su credenze culturali profondamente radicate. La nostra ricerca si basa sulla revisione degli articoli pubblicati in letteratura dal 2009 al 2019, mediante la consultazione di banche dati quali PubMed e Cochrane Library, utilizzando parole chiave collegate tra loro dall’operatore AND, operatore logico dell’algebra di Boole. I dati recentemente pubblicati mostrano come questa pratica sia tutt’ora esercitata, nonostante la giurisdizione nazionale e internazionale riconosca le mutilazioni genitali femminili come un reato perseguibile. Vogliamo sottolineare che tale fenomeno non riguarda solo i paesi africani: i flussi migratori hanno infatti esportato le mutilazioni genitali femminili anche in Europa, in America e in Australia. In questi paesi emerge quindi la necessità di formare ed accrescere le conoscenze del personale sanitario che si trova ad affrontare il problema delle mutilazioni genitali e che dovrà mettere in campo trattamenti di presa in carico e di cura idonei per le donne che hanno subito tali orrende torture. L’eliminazione di queste pratiche mutilanti potrà avvenire attraverso campagne di sensibilizzazione in grado di favorire un adeguato livello di istruzione, capace di accelerare i progressi socioculturali che contribuirebbero a debellare tale disumana procedura nelle popolazioni che ancora sottacciono queste pratiche.

Parole chiave. Mutilazioni genitali femminili, circoncisione femminile, infibulazione, violenza, genere, diritti.

Introduction

With the expression ‘female genital mutilation’ (FGM), the World Health Organization (WHO) indicates any form of partial or total removal of part or all of the external genitalia, for cultural and non-therapeutic reasons, classifying them in four categories: partial or total removal of the external portion of the clitoris or foreskin (clitoridectomy); removal of the labia minora and labia majora (excision); narrowing of the vaginal ostium by suturing (infibulation) and other procedures not well classified, such as punctures, piercings and cauterization, with burns of the clitoris and surrounding tissues.1 Unfortunately, this practice is still existing, affecting women all over the world and crossing all borders, not only geographic, but also social, religious, cultural and economic. It is estimated that around 200 million women and girls have suffered from and live with the effects of this practice. Moreover, approximately 3.6 million children and girls could be subjected to external genital mutilation every year.1 FGM is to be considered a brutal and humiliating practice that violates the rights of the human being outlined in the Universal Declaration of Human Rights adopted by the General Assembly of the United Nations since 1948.2 The FGM phenomenon is a health issue, originating from several erroneous motivations – including mistaken social, cultural and religious beliefs, that cause the fear of exclusion and marginalization from the social context. FGM represents the justification to respect deeply rooted cultural beliefs about the role of women. In most cases, mutilations are generally carried out by elederly and influential women,

without anesthesia, with rudimentary tools and in precarious hygienic conditions.2 Mutilations can cause complications in childbirth and other very serious disorders, including profuse bleeding, abscess formation, pelvic infections, tetanus, sepsis, urinary tract infections, hepatitis and HIV.3-4 Furthermore, infibulation – the most widely adopted practice – causes severe discomfort both for the physical pain and for the “disharmonious sensation” of losing the feminine characteristics. In African societies, the creation of gender identity goes through the physical manipulation of the bodies involving the removal of the woman’s genitals, rather than being a natural path of development and growth of the female body. It represents a real aberration, a form of torture and an insult to the dignity and health of the women and girls who, against their will, are subjected to this practice3. Violence is a term that derives from ‘violate’, or ‘break the limits’, meaning an action whose purpose is to cancel the women’s identity and to destroy a part of their will. According to WHO, violence against women is defined as any act of violence based on gender that involves the intentional use of force, also carried out with coercion.1 This definition epitomizes the practice of FGM also with regard to the loss of gender identity. Indeed, for some cultures, women can identify themselves with the female gender only after having undergone the mutilation of their genitals.3 Deprivation of one’s rights means above all denial of the right to life, freedom and safety of one’s person, safety also intended as a form of protection from cruel, inhuman and humiliating tortures, brutal treatment or punishment, such as those provoked by and related to FGM2. When we talk about violence against women, too often we forget to include genital mutilation, thus leaving dormant, in a sort of ‘silence’, a form of violence still widespread and practiced on girls under the age of 18, who therefore – being minors and entrusted to parental roles – do not even have the right to oppose this horror from a juridical point of view. The practice of FGM is still employed today, mainly in Africa, but the emigration phenomenon helped spread it in Europe, America and Australia, thus making it ubiquitous. From this also emerges the need to train and increase the knowledge of the healthcare professionals and operators, who will have to face the problem of genital mutilation by implementing suitable treatments and linkage-to-care solutions.

Methodology

The study was conducted through the review of the literature data for the last decade, with a selection of relevant articles by title and text content, using the PubMed and Cochrane Library databases. For the purpose of the research, the following keywords were identified: Female Genital Mutilation, Female Circumcision, Transcultural Nursing, Deinfibulation, linked by the Boolean operator AND. The reference population in the research relates to women under the age of 18. The limits set for the search were the publication period from 2009 to 2019, with text in Italian/English, available abstracts and free full text. From the analysis of the literature, 104 articles were found and, at the end of the review, it was decided to analyze 10 studies which met the inclusion requirements required by the research (Figure 1).




Results

Ten relevant studies were identified from the literature review. The causes of FGM and the origins of this practice have been investigated. The investigation showed how, in the Countries where FGM phenomenon started – essentially the African continent – the origin of the procedure, strongly related to local traditions, are well rooted and how this custom, despite being a seriously mutilating practice for the young woman, hasn’t been abandoned yet.4-5 Furthermore, it emerged that this practice is being maintained even despite the constant and strong migratory movement towards the so-called “civilized Countries” and a legal system which, through the promulgation of opposing laws, adopts instruments that recognize the practice as a crime, both nationally and internationally.6 Abdulcadir et al. in their study analyze the treatment and management of women subjected to mutilation, including the possible surgical interventions to which the woman can or must be subjected after the practice. This study shows that, in order to ensure natural childbirth and prevent harm to the new borns, the woman must undergo deinfibulation, that is, the reopening of the “seal” created during the infibulation procedure. Furthermore, following the surgical practice of deinfibulation, the woman can undergo the reconstruction of the clitoris, in order to restore a physical harmony to the body, due to a radical physical transformation, induced by the partial or total removal of the genitals.7 Berg et al. highlight the short- and long-term post-mutilation consequences and complications. The study shows that the psychological damage suffered by women as a result of the mutilating procedure is significant. Although the study highlights an important series of consequences that women can manifest after the practice, mutilation continues to be a phenomenon based on cultural, social and religious beliefs, which delay its eradication.8 The literature also emphasizes the influence of the migratory movement in conditioning the hosting populations to vary their cultural, social and religious beliefs. Indeed, it emerges a strong interaction between apparently different cultures and how the migratory flow has contributed to spreading the practice of mutilation, thus leading to a growing increase in cases, which is widespread in different geographical areas.4,9 According to WHO data, about 200 million women and girls underwent this practice and about 3.6 million girls and women are at risk every year.1 Balfour et al. address the issue of the skills of the healthcare professionals who deal with women victims of mutilations and, in particular, they underline the importance of nurse’s role, who takes care of women undergoing a mutilating procedure. Further analyses are essential to plan an effective clinical and efficient care model. Furthermore, it would be essential to train health workers, especially nurses, regarding the phenomenon of FGM, in order to develop information and training methods suitable for an adeguate care of these patients.10 In their study, Jiménez-Ruiz et al. analyzed Madeleine Leininger’s theoretical model of ‘transcultural nursing’, defined as a conceptual reference model to ‘understand’ the customs that drive these peoples to practice mutilation. According to this theory, female genital mutilation is a form of cultural ‘care’, and it is practiced by different ethnic groups with different cultures.11 Williams-Breault et al. reviewed the legislative aspects of the phenomenon and its community educational characteristics, in order to eradicate the spread of the practice. The study shows that it is necessary to disseminate further information in order to increase knowledge and be able to raise the educational level of the African populations on this phenomenon.6

Discussion

FGM is a health problem originating from several erroneous motivations – including alleged social, cultural and religious misconceptions, flawed belief that cause fear of exclusion and marginalization from the social context – and from the pretext of respecting deeply rooted cultural convictions. FGM is a practice belonging to the African continent by culture and the migratory phenomenon has played an important role in spreading this procedure, exporting it also to Europe, America and Australia, thus influencing the host country to adopt certain customs, albeit legally improper.5,9 The procedure of FGM is recognized as a crime, both nationally and internationally. In our Country there are various laws protecting mutilated women, which recognize health as the supreme good and guarantee the right to sexual and reproductive health. Article 583 bis of the Criminal Code relating to the practices of mutilation of female genital organs states that “anyone who, in the absence of therapeutic needs, causes a mutilation of female genital organs is punished with imprisonment from four to twelve years”. The penalty varies according to the extent of the injury caused to the woman and the age of the victim (aggravating in the case of a minor).12 In the Italian legislative landscape, the Ministry of Health promulgated Law 7 of 9 January 2006, entitled “Provisions concerning the prevention and prohibition of female genital mutilation practices”, on the basis of which the necessary measures were promoted to prevent, oppose and suppress the FGM practices. From this law derives the importance of issuing guidelines for healthcare professionals who work with immigrant communities from Countries where FGM practices are carried out. The purpose of the guidelines is to carry out prevention, care and rehabilitation activities for women already subjected to mutilation.13 The European legislative landscape, on the other hand, finds comfort in the 2011 Istanbul Convention, which is the first treaty that recognizes the existence of FGM practice in Europe. The Convention authoritatively calls upon the Member Countries to increase and spread preventive measures, as well as guaranteeing the obligation of protection and support to female victims. The Istanbul Convention thus becomes the first legally binding instrument regarding the prevention of violence against women.14 Also in the African continent there is a legislation on the human rights, namely “African Charter on Human and Peoples’ Rights” which came into force in 1986, thanks to the Organization of African Unity (OAU). This document recognizes the human, civil, political, economic and social rights of people, as well as committing African states to ensure the right to health of women, including sexual and reproductive health. Despite the presence of an important legislative document, which condemns the exercise of the mutilating practice, it is clear that the repressive measure is not in itself sufficient to definitively annihilate the procedure.14 The practice of FGM is also condemned by the WHO, which defines it an extremely traumatic act with serious consequences on the physical, mental and sexual health of women and young girls1. Just as the WHO recognizes the practice as harmful, UNICEF and UNFPA (United Nations Fund for Population Activities) also join forces in providing their contribution in defending human rights for women and girls.1,15 Every year, in fact, on February 6, the International Day of Zero Tolerance, Stop Female Genital Mutilation is celebrated to underline that the phenomenon must be completely eradicate, and not simply reduced in its incidence.1 In fact, in 2015, the various humanitarian organizations agreed on the urgency of the elimination of FGM, inserting it among the Sustainable Development Goals for 2030, setting the definitive eradication of the phenomenon by that date. The Sustainable Development Goals to be achieved by 2030 are 17 and, in particular, number 5 concerns the phenomenon of genital mutilation: “Achieving gender equality and improving the living conditions of women” in order to eradicate all forms of violence against women, in the private and public spheres, including sexual exploitation.16 From the healthcare perspective, the nursing model that comes closest to taking care of victims of mutilation is represented by the theory of “Transcultural Nursing” by Madeleine Leininger, precisely because it draws its foundation from cultural, social and religious inferences, which are the basis of the definition of the determinants of health described in the conceptual model.11 This model helps to “understand” the reasons why different ethnic groups can find solutions to different cultural approaches, where the meaning of the practice is not shared, but an attempt is made to read the underlying reasons. This reading allows to bring the different positions closer, and undoubtedly promotes the acquisition of nursing skills. Taking care of human beings is a universal phenomenon, but the modes, processes and patterns vary from one culture to another. Culture is thus what connects universal principles to welfare principles.17 The presence of health workers who are able to meet the needs of these women is an important aspect, and it is therefore essential to evaluate the reasons that lead to the persistence of FGM in the affected communities. Health professionals, therefore, need training to respond to the health and psychological needs of women subjected to mutilation, also through the conscious desire to understand the cultural reasons for the phenomenon. In this setting, further studies are necessary to increase the health workers’ knowledge in FGM. The purpose of the studies should be directed towards the ability to build qualitatively effective and efficient care plans, which take into account health and clinical-care conditions, but also socio-cultural phenomena, which are the heritage of the various ethnic groups. It is necessary to implement campaigns of correct information on the mutilating practice, aimed at the population, in order to facilitate the dissemination of educational and prevention tools, in particular to spread the message related to gender violence and the violation of rights with regard to the public health of young women. The awareness campaigns, the education on the clinical, social and psychosexual complications of genital mutilation, the denial of the rights of young women and the fact that the practice has no health benefits should be a powerful deterrent to FGM. An adequate level of education becomes indispensable to improve gender relations and to accelerate the social progress that could contribute to eradicating this inhuman and horrendous practice.

Conclusions

FGM is still carried out mainly by groups and ethnic groups in Sub-Saharan Africa and the Arabian Peninsula, but it is also practiced in Europe, Central America, United States, Canada and Australia, due to the migratory flows (Figure 2). It is a still existing phenomenon that in some African Countries affects about 90% of the African female population; in fact the practicing populations are unable to separate themselves from this inhuman anthropological tradition, while admitting that it is a violation of human rights that involves serious health problems for young women. The review of the literature highlights the short- and long-term consequences of a woman undergoing mutilation. These are consequences on physical health – which involve an organic damage due to the impetuousness of the maneuvers applied by the practitioners during the procedure – but also on psychological health, due to the devastation of the body pattern that each woman projects on herself. These young victims suffer from anxiety, depression, fear and difficulty in interaction/relationship, attitudes that lead to a closure of the mutilated victim, with serious difficulties in expressing their needs. The woman in the reproductive phase can manifest gynecological complications such as hematocolpos, dysmenorrhea or amenorrhea, and in some cases a condition of infertility can occur, due to recurrent uro-genital infections caused by surgical procedure performed with septic maneuvers. She can also manifest complications related to childbirth, such as prolonged labor, hemorrhages and tissue lacerations caused by the modifications that the birth canal undergoes as a result of FGM.18 Due to the numerous epidemiological data, it becomes important for healthcare professionals to possess essential knowledge elements to better address the clinical, social and psychological problems of young mutilated women. FGM is a pressing understimated phenomenon, because people believe that this practice affects only the African populations. Unfortunately, the community, including the healthcare area, does not give attention to this phenomenon, since it is considered a form of violence far from our culture. This behaviour increases the risk of underrating this atrocious reality, instead of promoting a constructive debate among different cultures. Due to migratory flows, this inhuman, horrendous and disfiguring phenomenon is coming to light and it would be advisable to discuss it more, in order to face indifference and to better address the clinical, social and psychological problems of young mutilated women. It is necessary to use people’s knowledge about this phenomenon as a lever to create the correct expertise of health workers who take care of victims of genital mutilations, encountered in various clinical settings.19-20 FGM is a practice to be condemned, as well as a blatant manifestation of gender inequality. Only a great cultural commitment – both on the part of the Countries that still downplay these practices and of the emancipation of the women involved – can produce changes in favor of the elimination of the practice. The socio-cultural integration level of immigrants, together with the raising of the educational level of women, the scholastic integration of minors and the access to healthcare and social services, are indispensable prerequisites, capable of favoring the propensity to abandon such mutilating practices. Educating the population most exposed to the phenomenon, through awareness campaigns on the physical and psychological complications caused by genital mutilation, could be a foundamental step for the eradication of this gruesome practice.







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Acknowledgements This review is a summary of the graduation thesis of Dr Maria Riglia, Degree Course in Nursing at the University of Milan, Le mutilazioni genitali femminili come violenza di genere: revisione della letteratura (“Female genital mutilation as gender violence: a literature review”).

Author contribution statement: all the Authors are responsible for the contents and have read and approved the final version of the article.

Conflict of interest statement: all the Authors declare no conflicts of interest.

Correspondence to:

Franca Di Nuovo

ASST Rhodense

Viale Forlanini 95

20024 Garbagnate Milanese (Mi), Italia

email fdinuovo@asst-rhodense.it