1 Faculty Of Pharmacy, University Of Benin, Benin City. Nigeria.
Tel: 234 – 52 – 602009; Fax: 234 – 52 – 602009 Email: fobuekwe@uniben.edu ; ifobuekwe@hotmail.com
2 Faculty Of Medicine, University Of Benin, Benin City. Nigeria.
Tel: 234 – 52 – 257178 Email: egbagbe@uniben.edu
Key words
dysmenorrhea, female genital mutilation, consequences, women’s health, complications..
Abstract
Female genital mutilation (FGM) constitutes all procedures, which involve partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or any other non-therapeutic reasons (WHO). Infibulation is the most extreme form of FGM and constitutes approximately 15% of all procedures. It involves the complete removal of the clitoris and the labia minora, as well as the inner surface of the labia majora. Since a physical barrier to intercourse has been created, the infibulated woman has to undergo gradual dilation by the husband after marriage. This is usually very painful and may take several days. Sometimes, it is not possible for the husband to penetrate at all, and the opening has to be re- cut.
At childbirth the trauma of mutilation is repeated. The woman has to be defibulated to allow the passage of the baby. Infibulations cause most damage in girls and women’s health in the immediate and long term. Dysmenorrhea is a recurrent painful disease, which causes physical and psychological stress in women. Irregular menstrual periods are much more common at the extremes of reproductive life.
One of the irregularities in menstruation is dysmenorrhea, which is a menstrual cramp and is suffered by some girls and women. This does not usually start until 2 or 3 years after menarche and it usually occurs if the menstrual period follows a cycle in which ovulation occurred. But occasionally, it occurs in a period in which ovulation did not occur, particularly if the menstrual blood in the uterus and the small clots are then expelled. Early age of menarche, infection during FGM and long menstrual periods increase the occurrence, duration and severity of the pain.
This study examined the long-term consequences of dysmenorrhea in FGM among 150 women aged between 30 and 60 years in an urban community, Benin City, South -West Nigeria. Well-structured, in-depth questionnaires were used for the study. All the 150 respondents were circumcised either at birth (50%), puberty (37.3%) and during first pregnancy (13%). The ages at first period for the respondents ranged from 14 to 17 years and the days between two periods last for 3 to 7 days. Most of the respondents experienced severe pains during the periods and used analgesics. For some of the respondents, pain subsided after childbirth (75%), as they grew older (12.5%) or still persisted (12.5%).
The reasons given to justify FGM were numerous and reflect the ideological and historical situation of the societies in which it was developed. Reasons cited were generally relative to tradition, power inequalities and the ensuing compliance of women to the dictates of their communities. Other reasons given for practice of FGM were custom and tradition, purification, family honour, protection of virginity and prevention of promiscuity, enhancing fertility and increasing matrimonial opportunities.
This study then suggests that there must be a correlation between dysmenorrhea and FGM among these women especially when it is known that blood clots could be retained during menstruation for those who have undergone FGM. Those who practice FGM, which continues to be a sensitive subject, may often believe in it without perceiving all its repercussions. However, attitudes are gradually changing among some urban educated women.
Introduction
More than 100 million women and girls living today have undergone female genital mutilation (FGM) in some countries in the Arab World and sub-Saharan Africa,1,2,3 in parts of Asia4 and in migrant populations in Europe, Australia and North America.5
The practice
FGM is a deeply rooted, traditional cultural practice dating from antiquity, which involves the removal of parts of healthy external female genital organ. FGM, which is an assault on the integrity of the person, comprises the health of the young infants adolescents and women on whom it is performed. It also affects the right of women to understand value and enjoy then sexuality4. The three broad categories of FGM are clitoridectomy, excision and infibulation. The mildest form of FGM, clitoridectomy is the removal of all or part of the clitoris. Excision includes the removal of the clitoris and the cutting of the labia minora. The most extreme form of FGM is infibulation, the removal of the clitoris, labia minora and the stitching together of the labia majora. Infibulation leaves just a small opening in the vagina for the passage of urine and menstrual fluid, and requires binding together of the legs until stitches adhere. The removal of the stitches often is part of a wedding right ritual6. At childbirth the trauma of mutilation is repeated. The woman has to be defibulated to allow the passage of the baby. Infibulation causes most damage in girls' and women’s health in the immediate and long-term.
The time of performing the practice varies from one culture to the other, FGM is usually performed on girl between the neonatal Renamed (one week old) when she reaches the age of 10 or at adolescence at the time at manage or at 1st pregnancy it is usually performed between the ages of 5 and 9 years 7,8,9,10. FGM seems to be occurring at earlier ages in several countries because parents want to receive the trauma to than children. The mutilation is usually performed under non-hygienic conditions, by traditional medical practitioners with no anaesthetic, using non-sterile crude instruments, such as knives, razor blades and broken glass or even with teeth. These instruments are rarely cleaned and are usually used in succession causing transmission of some viral and other infections such as HIV/AIDS11,12,8. FGM is likely to increase the risk of HIV infection because most times the same un-sterilized instruments are used on several girls at a time, thereby increasing the chances of spreading communicable diseases and HIV infections Female genital mutilation is a painful and dangerous practice13. It is a dramatic example of how gender can affect health14
Socio-cultural factors
There are many gaps in knowledge concerning female genital mutilation. In many countries the underlying socio – cultural, gender and economic factors that predict and influence the practice and the morbidity by type of FGM are not equally documented 15. All societies have norms of care and behavior based on age, life stage, gender and social class. These norms often called traditional practices, may be beneficial or harmless but sometimes may be harmful16.
FGM also known as female circumcision is increasingly considered a form of female sexual abuse. Evidence has shown that it can lead to long-lasting psychological and physiological damage and harm to women’s reproductive health. This could be seen as a form of violence and consequently a denial of women’s and girls fundamental human rights17. Where FGM takes place in late childhood through adolescence, it may be a ritual for girls just before menarche. It is also part of ceremonies in other cultures to initiate girls into womanhood19. The young women learn their responsibilities as future wives, community members and mothers receiving instructions in their peoples tradition and matter such as hygiene during such puberty rituals. In most African countries, FGM is performed in both urban and rural areas. Some migrants usually go back to their home countries from areas where FGM is illegal to perform the ritual20
Those who condone FGM cite a number of justifications for it including religions, socio-cultural psychosexual, hygienic and aesthetic reasons. The reasons for practicing circumcision vary in different areas and are associated with perception of religions, health, moral and social acceptability. There are also belief that FGM protects a girls virginity, increases a girl’s chance of marriage, improves fertility or prevent still birth, discourages promiscuity21. In 1997 a reproductive health survey in Fayoum, Egypt and in Sierra Leone women were asked about reasons for FGM22, 23. Their responses are shown in Table 1.
FGM is also thought to help prevent infant and child mortality. The Bambara & Dogon (Mali), some Nigeria groups and the Mossi (Burkina Faso) believe that the child may be killed at birth if the clitoris is present 24,25. FGM is a prerequisite for marriage eligibility in many areas25,26
FGM is a prerequisite for marriage in many areas27. Where women are largely dependent on men, economic necessity can be a major determinant of their willingness to undergo the procedure, FGM. In some African countries, uncut women are considered illegitimate and ineligible to inherit money land or cattle23. Most women who have had the FGM procedure are strongly in favor of FGM for their daughters29. Fifty per cent of the women surveyed in Egypt reported that they had at least one daughter who had gone through the procedure.
Table 1: Responses from a reproductive health survey from married women in Egypt and Sierra Leone9
Adapted from De Bruyn M18
Table 2a. Delayed complications of FGMa
Adapted from EL Dareer33
Painful scan of keloid |
Vulval asbcess |
Recurrent UTI |
Chronic pelvin infection |
Difficult penetration |
Pain during intercourse |
Difficulty in menses |
Inclusion light |
Total |
No Implications |
11 (1.07%) |
143 (13.9%) |
283 (27.6%) |
241 (23.5%) |
231 (22.5%) |
56 (5.4%) |
39 (3.8%) |
19 (1.8%) |
1023 |
2185 |
Table 2b: Immediate Complications of FGM Adopted from EIDareer 33
Adopted from EL Dareer33
bleeding |
shuk |
swelling |
fever |
Wound infection |
Difficulty in passing urine |
Urine retention |
Total |
No complication |
168 |
31 |
51 |
133 |
151 |
172 |
84 |
790 |
2375 |
Table 3: Complications in Children
Adopted from Egwuatu and Agugua 34
Haemorahge |
Septicaemia |
Urinary |
tetanus |
Labial fusion |
Urine retention |
Recto-vaginal fistula |
Dermoid cyst |
Intercoital swelling |
2 |
1 |
2 |
1 |
21 |
12 |
1 |
9 |
2 |
Consequences of FGM
The actual number of girls who die as a result of FGM is unknown. Where medical faculties are ill - equipped, emergencies arising from the practice cannot be treated. Thus, a child who develops uncontrolled bleeding or infection after FGM, may die within hours30.
The forms of FGM vary widely and so do its consequences. However, common immediate risks include hemorrhage shock30, infection (bacterial /viruses e.g. HIV), septicemia pain, failure to heal and even death, urine retention from swelling and/or blockage of the urethra, damage to adjoining organs from the use of blunt instruments by unskilled operators31, wound infection including tetanus10. Long-term physical effects can include acute or chronic pelvic infection; scarring and keloid formation, recurrent urinary tract infections31, increased risk of maternal and child morbidity and mortality due to obstructed labor. It has been reported that women who have undergone FGM are more likely to give birth to a stillborn child and are also twice likely to die during childbirth than other women32. Dymenorrhea, disparunia and infertility are also long-term consequences of FGM.
Dysmenorrhoea is a menstruation that is accompanied by either sharp, intermittent pain or dull, aching pain in the pelvis or lower abdomen. Common causes of include premenstrual syndrome (PMS). Intrauterine device (IUDs) used for birth control, stress and poor health or as a result of pelvic inflammatory disease. The causes of this symptom can include unlikely diseases and medications. It could also be based on the specific characteristics of the symptom such as aggravating factors (like FGM), relieving factors and associated complaints.
Painful menstruation affects half of menstruating women and is the leading cause of lost time from school and work among women of childbearing age. This pain may precede menstruation by several days or may accompany it and usually subsides as bleeding tapers off. Some pains during menstruation is normal; excessive pain is not. Dysmenorrhoea refers to menstrual pain severe enough to limit normal activities and require medication. The incidence of menstrual pain is greatest in women in the late terms and twenties, then declines with age. An estimated 10 to 15% of women experince menstrual pain each month, severe enough to prevent normal daily function at school, work or home. The majority of women will suffer this degree of disability at least once during their reproductive years. Increased risk is associated with younger age.
This study examined the long-term consequences of dysmenorrhoea in FGM amongst women in an urban community Benin City, Edo State, South – West Nigeria.
Methodology:
This study examined the long-term consequences of dysmenorrhea in FGM among 150 women aged between 30 and 60 years in an urban setting, Benin City, Edo State, South –West Nigeria. Well-structured, in-depth questionnaires were used for the study.
This study also tried to investigate if there was any correlation between dysmenorrhoea and FGM. Those respondents who could not write or where interviewed and responses recorded
Results
The ages of the respondents ranged between 30 and 60 years. (Table 4). The results from this study showed that all the respondents were circumcised either at birth (50%), puberty (37.3%) or during first pregnancy (13%) . Also ages at menarche ranged from 14 to 17 years and the days between two periods lasted for 3 to 7 days (Table5)
Most of the respondents experienced severe pains during the periods and used analgesics. For most, pains subsided after childbirth (75%), as they grew older (12.5%) or still persisted (12.5%) (Table 6).
The reasons given to justify FGM were numerous and reflect the ideological and historical situation of the societies in which it was developed. Reasons cited were generally relative to tradition, power inequalities and the ensuing compliance of women to the dictates of their communities. Other reasons given for the practice of FGM were custom and tradition, purification, family honor, protection of virginity and prevention of promiscuity, enhancing fertility and increasing matrimonial opportunities (Table 7).
Table 4. Age Distribution and Social Status of the Respondents.
a. Age |
Number of Respondents |
% |
30-39 |
30 |
20 |
40-49 |
45 |
30 |
50-59 |
45 |
30 |
60-69 |
30 |
20 |
b. Marital Status |
No. of Respondents |
% |
Married |
105 |
70 |
Divorced |
15 |
10 |
Widowed |
30 |
20 |
c. Occupation |
No of Respondents |
% |
Worker |
105 |
70 |
Housewife |
15 |
10 |
Trader |
30 |
20 |
Table 6. Respondents that were Circumcised.
a. Circumcision |
% |
|
150 |
100 |
|
b. Circumcised by whom. |
No of Respondents |
% |
Traditional Midwife |
135 |
90 |
Hospital Midwife |
15 |
10 |
c. When was circumcision done |
No of Respondents |
% |
At Birth |
90 |
60 |
Puberty |
45 |
30 |
First pregnancy |
15 |
10 |
Table 7. Reasons given to justify FGM.
Reasons |
No of Respondents |
% |
FGM must continue |
105 |
70 |
Custom & traditions |
120 |
80 |
Protection of virginity |
90 |
60 |
Prevention of promiscuity |
135 |
90 |
Family honor |
75 |
50 |
Increasing matrimonial opportunities |
120 |
80 |
Table5. Reproductive health status of the Respondents.
a. Age at menarche |
No of Respondents |
% |
14 |
30 |
20 |
15 |
90 |
60 |
17 |
30 |
20 |
b. Duration of periods
Days |
No of respondents |
% |
3 |
30 |
20 |
5 |
90 |
60 |
7 |
30 |
20 |
c. Days between periods
.
Days |
No of Respondents |
% |
27 |
45 |
|
28 |
05 |
d. Very painful periods
i. |
Yes |
% |
No |
% |
Sometimes |
% |
90 |
60 |
30 |
20 |
30 |
20 | |
ii. When do you have pains
Before periods |
% |
During periods |
% |
All through |
% |
75 |
50 |
45 |
30 |
30 |
20 |
iii. When did the pain stop?
After birth |
% |
As they grew older |
% |
Pain till persist |
% |
113 |
75 |
18 |
12.5 |
17 |
12.5 |
Discussion
In the past, circumcised women have not always received sensitive and appropriate care from the maternity services. There is anecdotal evidence of health professionals misdiagnosing FGM as genital deformity and routinely referring for cesarean section35.
The infibulation during FGM presents tremendous health problems to the girl later in life, if she survives the initial trauma of the operation. The various degrees and types of urinary obstruction are a frequent result of infibulation, and concomitant urinary tract infection are very common in pharaonically circumcised women.36,27,37,38. Various studies showed that the target group are the young girls (commonly below 10 years), but it is also clear that a new born girl in the fist week of her life may be circumcised 39. This correlated with our findings where most of the respondents (50%) were circumcised at birth. For some, circumcision was done adulthood40, showing that FGM is deeply rooted in the traditions of the people. This also correlated with our findings where about 37.3% of respondents were circumcised at puberty.
Dysmenorrheic condition is relieved or cured by pregnancy or childbirth, especially in cases of primary dysmenorrheae. In this study, for some of the respondents said that pain subsided after childbirth. Mild to moderate cases of dysmenorrhea can usually be treated with aspirin as well as the local use of heat by taking a hot bath41.
The onset of menstruation generally creates a tremendous problem for the girl as the virginal aperture is inadequate for menstrual flow, an infibulated virgin suffers protracted and painful periods of menstruation with a great deal of blockage retention and buildup of clots behind the infibulation. More problems may arise during pregnancy and delivery. If a woman is tightly closed, catheterization may be difficult. Difficulties in menstruation often occur because of partial or total occlusion of the vaginal opening. This may result in dysmenorrhoea.
Conclusion And Recommendations
Almost all types of female genital mutilation involve the removal of part or the whole of the clitoris, which is the main female sexual organ.
Many women believe that FGM is necessary to ensure acceptance by their community and they are not aware that FGM practice is not global. Women who are subjected to the severe forms of FGM are likely to suffer from reproductive health problems throughout their lifetime. Some complications can occur immediately while others occur years after the practice. In this era when HIV/AIDS is a global emergency, the risk of its transmission is likely to be higher for women with FGM, as a result of scar tissue. During sexual or anal intercourse, the small vaginal opening is prone to laceration due to inability to penetrate the vagina. When children are simultaneously mutilated with the same instruments, HIV may also be potentially transmitted.
Many reasons given for FGM practice are related to tradition, non-empowerment of women, and women complying with the dictates of their communities.
Recommendations from this study:
- Complications: The health consequences in FGM practice namely; dysmenorrhea, bleeding, UTI, infertility, HIV transmission and incontinence must be made known to the communities involved.
- Training of Traditional Healers and Birth Attendants: That the practice should not be enforced, but where the communities insist, traditional healers and birth attendants must be trained and informed to use sterile instruments for FGM.
- Counseling: FGM practice cannot reduce promiscuity amongst adolescents as is thought in most African settings, therefore counseling should be included as a possible intervention, so that women and girls can have the opportunity to express their fears and concerns about their sexuality.
- Community Outreach: Dissemination of information through the mass media (Radio/TV), town criers and all available channels to communicate information to all sectors of the public.
- Men’s Participation: This should involve community and religious leaders. Men should also be involved as they are the custodians of traditions and customs in most African settings. When women find support from their brothers, fathers and partners, definitely, their attitudes toward FGM practice will change.
- Role of NGOS: Women organizations and leaders should organize education programs which address the main reasons to sustain the continuation and practice of FGM.
The practice of FGM must be addressed as a public health issue. Strategies for its elimination and prevention should be incorporated into school health programs, health education curricula and also HIV/AIDS control programs.
Attitudes however, are gradually changing amongst some educated urban women.
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