1 Female Genital Mutilation Survey - Edna Adan University Hospital This report is an independent publication based on research commissioned and carried out by the Edna Adan University Hospital over a seven year period. It is the product of a collaborative effort involving members of hospital staff, students and volunteers. The report was published in partnership with Orchid Project in 2016. For more information about the report, please contact: Edna Adan Foundation Email: [email protected] Tel: +44 (0)7736 932 030 www.ednahospital.org © Edna Adan University Hospital, 2016 All rights reserved First Edition Graphic design by Olivia Comberti Photos by Sarah Winfield Acknowledgements Acknowledgements We wish to express our sincere thanks to Orchid Project for their guidance and support in facilitating the publication of this study. In addition, we’d like to acknowledge the invaluable contributions made by members of staff and students who collected data and recorded findings on antenatal charts. We are grateful also to the midwives and doctors who provided antenatal care and supervised students during their rotation in the department. Finally, special thanks are reserved for the administrative staff who undertook the arduous and painstaking task of recording the collected data. 2 Female Genital Mutilation Survey - Edna Adan University Hospital Contents Acknowledgements ................................................................................................ 2 What is Female Genital Mutilation? ....................................................................... 5 Classification ............................................................................................................................. 5 Global prevalence ..................................................................................................................... 6 Studies on FGM/C ..................................................................................................................... 7 FGM/C in Somaliland ................................................................................................................ 8 The Procedure ...................................................................................................... 10 Instruments and methods ....................................................................................................... 10 The operation ......................................................................................................................... 11 De-infibulation at the time of marriage .................................................................................. 13 The Dangers of FGM/C ......................................................................................... 13 Complications ......................................................................................................................... 14 Reasons Given for FGM/C ..................................................................................... 17 Campaign to Eradicate FGM/C .............................................................................. 19 The international campaign .................................................................................................... 19 The campaign in Somalia/Somaliland ..................................................................................... 20 Location of Study: The Edna Adan University Hospital .......................................... 22 Health profile of the people of Somaliland ............................................................................. 23 Services provided by the Hospital ........................................................................................... 24 Hospital objectives .................................................................................................................. 24 The Hospital and FGM/C ......................................................................................................... 25 The Study ............................................................................................................. 27 Purpose of surveys .................................................................................................................. 27 Methods of data collection ..................................................................................................... 27 Questionnaire ......................................................................................................................... 28 3 Female Genital Mutilation Survey - Edna Adan University Hospital Findings ................................................................................................................ 29 1. Age of women ..................................................................................................................... 29 2. Prevalence of FGM/C .......................................................................................................... 29 3. Type of FGM/C .................................................................................................................... 30 4. Age at which FGM/C was performed .................................................................................. 31 5. Countries where FGM/C was performed ............................................................................ 32 6. Where FGM/C was performed: urban or rural areas .......................................................... 33 7. Persons performing FGM/C ................................................................................................ 34 8. Perceived reasons for having undergone FGM/C ............................................................... 34 9. Number of women who would perform FGM/C on their daughters .................................. 35 10. Type of FGM/C women would perform on their daughters ............................................. 36 11. Reasons given for performing FGM/C on their daughters ................................................ 37 12. Women’s level of education ............................................................................................. 38 13. Women’s level of education compared with whether they underwent FGM/C .............. 39 14. How the decision to perform FGM/C on daughters varies with women’s education ....... 40 15. How the decision to perform FGM/C on their daughters differs between women with and without FGM/C ................................................................................................................ 42 16. How the reasons given for women’s own FGM/C varies with the reasons given for performing FGM/C on their daughters ................................................................................... 43 Recommendations ............................................................................................... 45 Conclusion ............................................................................................................ 50 4 Female Genital Mutilation Survey - Edna Adan University Hospital What is Female Genital Mutilation? What is Female Genital Mutilation? The World Health Organization (WHO) defines Female Genital Mutilation (FGM/C) as all procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons.1 It is practised in more than 25 countries throughout Africa, the Middle East and Asia, and within diaspora populations across the world. FGM/C prevalence rates range from 5 to 99% and it is practised among all religious, ethnic, cultural, and socio-economic groups. Also known as female circumcision (FC), or female genital cutting (FGC), FGM/C results in many health-related and potentially life threatening complications, as well as physical and psychological problems that do great harm to the wellbeing of women and children who have had it performed on them. Unlike male circumcision, FGM/C is not a religious obligation required by Islam, Christianity, Judaism, or any other religion. Figure 1: Normal female genitalia Classification 2 Procedures vary across the world but the WHO classifies FGM/C into four types. These are: Type I: Excision of the prepuce with or without excision of the clitoris Figure 3: FGM/C Type I Type II: Excision of the clitoris with partial or total excision of the labia minora Figure 2: FGM/C Type II 1 World Health Organization, Female Genital Mutilation - a teacher’s guide. WHO, Geneva, 2003 2 World Health Organization, Female Genital Mutilation - a teacher’s guide. WHO, Geneva, 2003. 2 World Health Organization, Female Genital Mutilation - a teacher’s guide. WHO, Geneva, 2003. 5 Female Genital Mutilation Survey - Edna Adan University Hospital Type III: Excision of part or all of the external genitalia and stitching together of the exposed walls of the labia majora, leaving only a small hole (typically less than 5mm) to allow the passage of urine and vaginal secretions. This hole may need extending at the time of the menarche and often before first intercourse Figure 4: FGM/C Type III Type IV: Unclassified, covering any other damage to the female genitalia including pricking, piercing, burning, cutting or the introduction of corrosive substances.3 It should be noted that Type IV is not practised in Somaliland. Global prevalence FGM/C is a widespread practice that is carried out on young girls between the ages of 5 and 10, and, in some countries, on grown women as well. It is estimated that up to 133 million women and girls globally have been subjected to some form of FGM/C with a further 30 million said to be at risk over the next ten years.4 In countries where either most or a large number of women have undergone the procedure, the medical complications that result place a heavy burden on health services. In Asia, FGM/C is occasionally reported as being practised by a limited few in Oman, Saudi Arabia, United Arab Emirates, Yemen, and in certain communities in Indonesia, Malaysia, India, and Pakistan.5 However, it is reported to exist in many African countries. In some, it is performed on most or all women while in others it may be carried out only on women belonging to certain ethnic groups. These countries include: Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Democratic Republic of the Congo, Djibouti, Egypt, Eritrea, Gambia, Ghana, Guinea, Guinea- Bissau, Ivory Coast, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, Somalia, Somaliland, Sudan, Tanzania, Togo, and Uganda.6 3 It is noteworthy that a recent study in Somalia and Somaliland found a ‘high level of variation in excision and divergence of local terms and interpretations from the WHO FGM/C types’ listed above. The research suggests that Sunna is used in many communities to refer to ‘any type of circumcision which people believe is required/sanctioned by Islam.’ Two variations of Type III FGM/C were identified – Sunna Kabiir (less stitching) and Fadumo Hagoog (excision but no stitching) – and other increasingly radical forms labelled as Sunna have evolved into variations of Type II and Type III. – Crawford, S. & Ali, S. Situational Analysis of FGM/C/C Stakeholders in Interventions in Somalia. UNFPA-UNICEF, UK AID, London, p. 57. 4 United Nations Children’s Fund, Female Genital Mutilation/Cutting: What might the future hold? UNICEF, New York, 2014. 5 United Nations Children’s Fund, Female Genital Mutilation/Cutting: A statistical overview and exploration of the dynamics of change, UNICEF, New York, 2013. 6 Ibid 6 Female Genital Mutilation Survey - Edna Adan University Hospital In recent years, because of immigration and population movements, the practice has been emerging among refugee populations in Europe and North America where the treatment sought by women for medical complications as a result of FGM/C is a major source of anxiety among health care providers. This concern is reflected by the attention FGM/C receives from international health and human rights organisations as well as the world’s media. Studies on FGM/C UNICEF is the leading agency providing data and resources on FGM/C in the 29 countries where the practice is currently measured. The 2013 statistical overview provided the most comprehensive review of available data to date, analysing prevalence and trends in the practice from more than 70 nationally representative surveys over a 20-year period.7 The report found that: more than 125 million women and girls have undergone FGM/C; 30 million girls are at risk of being cut in the next decade; social norms and expectations play a strong role in perpetuating the practice; FGM/C is becoming less common in slightly more than half of the 29 countries studied; and in most countries where FGM/C is practised, the majority of girls and women think it should end. The report found that in Somalia: at least 80 per cent of girls are cut between the ages of 5 and 14, more than one in five girls have undergone infibulation; and there has been no significant change in prevalence. According to preliminary findings, the prevalence of FGM/C is 98% in the Northeast Zone and 99% in Somaliland, and the percentage of girls and women aged 15 to 49 who think the practice should continue is 58% in the Northeast Zone and 29% in Somaliland. Between 1995 and 2002 the Demographics and Health Surveys published data comprising questionnaires from 16 countries. Somaliland and Somalia, however, were not included. Prior to this, the most comprehensive report was that of Yoder (2004).8 Some of the most accurate early data on FGM/C came from Fran Hosken, who, in 1982, compiled statistics from her many years of studying FGM/C in Africa.9 Other landmark studies include the research carried out in the early 1980s by the Somalia Academy of Arts and Sciences into the physical, psychological, and sociological aspects of FGM/C. 7 United Nations Children’s Fund, Female Genital Mutilation/Cutting: A statistical overview and exploration of the dynamics of change, UNICEF, New York, 2013. 8 Yoder, P. S., N. Abderrahim and A. Zhuzhuni, Female Genital Cutting in the Demographic and Health Surveys: A critical and comparative analysis, DHS Comparative Reports No 7, ORC Macro, Calverton, MD, 2004. 9 Hosken, F. The Hosken report: Genital and sexual mutilation of females. Women’s International Network News. Lexington, Massachusetts, 1982. 7 Female Genital Mutilation Survey - Edna Adan University Hospital FGM/C in Somaliland It has long been accepted that FGM/C is ubiquitous in Somaliland, but accurate data has been lacking. Anecdotal evidence suggests that the procedure is commonly performed on girls between the ages of 4 and 11 and that 95 to 100% of women have undergone the procedure, the majority of whom have been subjected to the most severe form.10 11 12 In 1999, Care International carried out a study in Somaliland which found FGM/C to be universal, with 91% undergoing Type III. In 2000, another study carried out by the WHO and UNICEF to investigate HIV prevalence also asked women about their FGM/C status. Of the 769 women participating in the research, 98% had undergone Type III FGM/C.13 In 2011, a study carried out by UNICEF in partnership with the Somaliland Ministry of National Planning and Development (MNPD) showed an FGM/C prevalence rate of 99.1% among girls and women between the ages of 15 and 49.14 The studies included in this report indicate that more than 98% of women receiving antenatal care at the Edna Adan Hospital have had FGM/C. In Somaliland the women refer to their procedure by two names, the Sunna and the Pharaonic. The Sunna correlates with Type I and II but also involves the stitching of the anterior part of the genitalia to varying extents. The Pharaonic correlates with Type III, which is also known as infibulation. Many awareness campaigns (see p. 21) have been carried out in Somaliland over the past two decades, and, as a result, more Somalilanders are willing to discuss FGM/C openly and are increasingly concerned about the health risks associated with the procedure. 10 World Health Organization, Traditional practices affecting the health of woman and children; female circumcision, childhood marriage, nutritional taboos etc. WHO/EMRO Technical Publication; 1982, 2:1-360. 11 Female circumcision: female genital mutilation. International Journal of Gynecology & Obstetrics 1992; 37:149. 12 Female genital mutilation - World Health Assembly calls for the elimination of harmful traditional practices. Press release of the 46th World Health Assembly. WHO, May 12, 1993, Geneva. 13 World Health Organization. HIV/AIDS ASSESSMENT: sero-prevalence survey. Dr Adan Yusuf Abokor. ICD WHO UNICER. 2000. 14 UNICEF & Somaliland Ministry of National Planning and Development (MNPD). Somaliland. Multiple Indicator Cluster Survey, 2011 – Somaliland, Final Report, 2014, p. 100 (Sep 2014) 8 Female Genital Mutilation Survey - Edna Adan University Hospital