*Corresponding Author:

Dr. Tochukwu Christopher Okeke
Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Enugu, Nigeria.
E-mail: ubabiketochukwu@yahoo.com

Abstract

Nigeria, due to its large population, has the highest absolute number of female genital mutilation (FGM) worldwide, accounting for about one-quarter of the estimated 115–130 million circumcised women in the world. The objective of this review is to ascertain the current status of FGM in Nigeria. Pertinent literature on FGM retrieved from internet services [Google search on FGM in Nigeria, www.online Nigeria, PubMed of the national library of medicine www.medconsumer. Info/tropics/fgm.htm, Biomedcentral and African Journal Online (AJOL) (FGM)] and textbooks, journals, and selected references for proper understanding of the topic was included in this review. The national prevalence rate of FGM is 41% among adult women. Evidence abound that the prevalence of FGM is declining. The ongoing drive to eradicate FGM is tackled by World Health Organization, United Nations International Children Emergency Fund, Federation of International Obstetrics and Gynecology (FIGO), African Union, The economic commission for Africa, and many women organizations. However, there is no federal law banning FGM in Nigeria. There is need to eradicate FGM in Nigeria. Education of the general public at all levels with emphasis on the dangers and undesirability of FGM is paramount.

Keywords

Female genital cutting, Female genital mutilation, Harmful traditional practice, Nigeria

Introduction

Female genital mutilation (FGM) is defined by the World Health Organization (WHO) as all procedures which involve partial or total removal of the external female genitalia and/or injury to the female genital organs, whether for cultural or any other non-therapeutic reasons.[1] In Nigeria, subjection of girls and women to obscure traditional practices is legendary.[2] FGM is an unhealthy traditional practice inflicted on girls and women worldwide. FGM is widely recognized as a violation of human rights, which is deeply rooted in cultural beliefs and perceptions over decades and generations with no easy task for change.

Though FGM is practiced in more than 28 countries in Africa and a few scattered communities worldwide, its burden is seen in Nigeria, Egypt, Mali, Eritrea, Sudan, Central African Republic, and northern part of Ghana where it has been an old traditional and cultural practice of various ethnic groups.[2,3] The highest prevalence rates are found in Somalia and Djibouti where FGM is virtually universal.[2]

FGM is widely practiced in Nigeria, and with its large population, Nigeria has the highest absolute number of cases of FGM in the world, accounting for about one-quarter of the estimated 115–130 million circumcised women worldwide.[2] In Nigeria, FGM has the highest prevalence in the southsouth (77%) (among adult women), followed by the south east (68%) and south west (65%), but practiced on a smaller scale in the north, paradoxically tending to in a more extreme form.[2,4] Nigeria has a population of 150 million people with the women population forming 52%.[4] The national prevalence rate of FGM is 41% among adult women. Prevalence rates progressively decline in the young age groups and 37% of circumcised women do not want FGM to continue.[2] 61% of women who do not want FGM said it was a bad harmful tradition and 22% said it was against religion. Other reasons cited were medical complications (22%), painful personal experience (10%), and the view that FGM is against the dignity of women (10%).[2] However, there is still considerable support for the practice in areas where it is deeply rooted in local tradition.[2] The aim of this review was to ascertain the current status of FGM in Nigeria.

Materials and Methods

Pertinent literature on FGM was retrieved from internet services [Google search on FGM in Nigeria, www.online Nigeria, PubMed of the National Library of Medicine www. medconsumer. Info/tropics/fgm.htm, Biomedcentral and African Journal Online (AJOL) (FGM)] and textbooks, journals, and selected references for proper understanding of the topic was included in this review.

Origin and significance

FGM is a practice whose origin and significance is shrouded in secrecy, uncertainty, and confusion.[3] The origin of FGM is fraught with controversy either as an initiation ceremony of young girls into womanhood or to ensure virginity and curb promiscuity, or to protect female modesty and chastity.[5] The ritual has been so widespread that it could not have risen from a single origin.[3,6,7]

Types/variation of FGM in Nigeria

FGM practiced in Nigeria is classified into four types[8] as follows. Clitoridectomy or Type I (the least severe form of the practice): It involves the removal of the prepuce or the hood of the clitoris and all or part of the clitoris. In Nigeria, this usually involves excision of only a part of the clitoris. Type II or “sunna” is a more severe practice that involves the removal of the clitoris along with partial or total excision of the labia minora. Type I and Type II are more widespread but less harmful compared to Type III. Type III (infibulation) is the most severe form of FGM. It involves the removal of the clitoris, the labia minora and adjacent medial part of the labia majora and the stitching of the vaginal orifice, leaving an opening of the size of a pin head to allow for menstrual flow or urine. Type IV or other unclassified types recognized by include introcision and gishiri cuts, pricking, piercing, or incision of the clitoris and/or labia, scraping and/or cutting of the vagina (angrya cuts), stretching the clitoris and/or labia, cauterization, the introduction of corrosive substances and herbs in the vagina, and other forms.

In Nigeria, of the six largest ethnic groups, the Yoruba, Hausa, Fulani, Ibo, Ijaw, and Kanuri, only the Fulani do not practice any form.[9]

FGM varies from country to country, tribes, religion, and from one state and cultural setting to another, and no continent in the world has been exempted.[3] In most parts of Nigeria, it is carried out at a very young age (minors) and there is no possibility of the individual’s consent.[6] Type I and Type II are more widespread and less harmful compared to Type III and Type IV. In Nigeria, there is greater prevalence of Type I excision in the south, with extreme forms of FGM prevalent in the North. Practice of FGM has no relationship with religion. Muslims and Christians practice it, but it is more widely spread in Christian predominated parts of Nigeria.[2]

FGM and women’s rights

FGM is recognized worldwide as a fundamental violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes and constitutes an extreme form of discrimination against women. It involves violation of rights of the children and violation of a person’s right to health, security, and physical integrity, the right to be free from torture and cruel, inhuman, or degrading treatment, and the right to life when the procedure results in death. Furthermore, girls usually undergo the practice without their informed consent, depriving them of the opportunity to make independent decision about their bodies.

Reasons to justify FGM

The respondents gave reasons for FGM. They regarded FGM as a tribal traditional practice (our custom is a good tradition and has to be protected), as a superstitious belief practiced for preservation of chastity and purification,[10] family honor, hygiene, esthetic reasons, protection of virginity and prevention of promiscuity, modification of sociosexual attitudes (countering failure of a woman to attain orgasm), increasing sexual pleasure of husband, enhancing fertility and increasing matrimonial opportunities. Other reasons are to prevent mother and child from dying during childbirth and for legal reasons (one cannot inherit property if not circumcised). [11] In some parts of Nigeria, the cut edges of the external genitalia are smeared with secretions from a snail footpad with the belief that the snail being a slow animal would influence the circumcised girl to “go slow” with sexual activities in future. [12] However, FGM is often routinely performed as an integral part of social conformity and in line with community identity.[3]

Health consequences of FGM

An estimated 100–140 million girls and women worldwide are currently living with the consequences of FGM.[13] In Africa, about 3 million girls are at risk for FGM annually.[13] Despite the increased international and little national attention, the prevalence of FGM overall has declined very little.[14] The procedure has no health benefits for girls and women. Adverse consequences of FGM are shock from pain and hemorrhage,[10] infection, acute urinary retention following such trauma, damage to the urethra or anus in the struggle of the victim during the procedure making the extent of the operation dictated in many cases by chance,[6] chronic pelvic infection, acquired gynatresia resulting in hematocolpos, vulval adhesions, dysmenorrhea, retention cysts, and sexual difficulties with anorgasmia. Other complications are implantation dermoid cysts and keloids,[12] and sexual dysfunction.[6,10]

Obstetric complications include perineal lacerations and inevitable need for episiotomy in infibulated paturients. Others are defibulation with bleeding, injury to urethra and bladder,[10] injury to rectum, and purperial sepsis. Prolonged labor, delayed 2nd stage and obstructed labor leading to fistulae formation, and increased perinatal morbidity and mortality have been associated with FGM.[10] The mental and psychological agony attached with FGM is deemed the most serious complication because the problem does not manifest outwardly for help to be offered. The young girl is in constant fear of the procedure and after the ritual she dreads sex because of anticipated pain and dreads childbirth because of complications caused by FGM. Such girls may not complain but end up becoming frigid and withdrawn resulting in marital disharmony.[3]

Current situation of FGM in Nigeria

FGM is widespread in Nigeria. Some sociocultural determinants have been identified as supporting this avoidable practice. FGM is still deeply entrenched in the Nigerian society where critical decision makers are grandmothers, mothers, women, opinion leaders, men and age groups.[15] FGM is an extreme example of discrimination based on sex. Often used as a way to control women’s sexuality, the practice is closely associated with girls’ marriageability.[16] Mothers chose to subject their daughters to the practice to protect them from being ostracized, beaten, shunned, or disgraced.[14,17] FGM was traditionally the specialization of traditional leaders’ traditional birth attendants or members of the community known for the trade. There is, however, the phenomenon of “medicalization” which has introduced modern health practitioners and community health workers into the trade.[15] The WHO is strongly against this medicalization and has advised that neither FGM must be institutionalized nor should any form of FGM be performed by any health professional in any setting, including hospitals or in the home setting.[15]

Efforts to eliminate FGM in Nigeria

It is true that tradition and culture are important aspects of any society in helping to mold the views and behavioral patterns of the society; some traditions and cultural beliefs and practices like FGM are harmful and must be abolished. A multidisciplinary approach is needed to tackle this deeprooted legendary practice of FGM. There is a need for legislation in Nigeria with health education and female emancipation in the society. The process of social change in the community with a collective, coordinated agreement to abandon the practice “community-led action” is therefore essential.[18] With improvement in education and social status of women and increased awareness of complications of FGM, most women who underwent FGM disapprove of the practice and only very few are prepared to subject their daughters to such harmful procedures.[3] The more educated, more informed, and more active socially and economically a woman is, the more she is able to appreciate and understand the hazards of harmful practices like FGM and sees it as unnecessary procedure and refuses to accept such harmful practice and refuses to subject her daughter to such an operation.

In 1994, Nigeria joined other members of the 47th World Health Assembly to resolve to eliminate FGM. Steps taken so far to achieve this include establishment of a multisectorial technical working group on harmful traditional practices (HTPs), conduct of various studies and national surveys on HTPs, launching of a regional plan of action, and formulation of a national policy and plan of action, which was approved by the Federal Executive Council for the elimination of FGM in Nigeria.

In Nigeria, FGM is being tackled by WHO, United Nations International Children Emergency Fund (UNICEF), Federation of International Obstetrics and Gynecology (FIGO), African Union, the Economic Commission for Africa (ECA), and many women organizations. Intensification of education of the general public at all levels has been done with emphasis on the dangers and undesirability of FGM. In 1995, Platform of Action adopted by the Beijing conference called for the eradication of FGM through the enactment and enforcement of legislation against its perpetrator.[19] However, there is no federal law prohibiting the practice of FGM in Nigeria. This is the main reason for the slow progress on declining the prevalence of FGM. Despite the increased international and little national attention, the prevalence of FGM overall has declined very little.[14] The prevalence depends on the level of education and the geographic location.[20]

At the grassroots, efforts should be taken to join in the crusade to say “NO” to FGM anywhere it is practiced among our people. It is crude, dangerous, wicked and unhealthy. FGM is not required by any religion and there is no scientific evidence that women who have been mutilated are more faithful or better wives than those who have not undergone the procedure.[15] It is very clear that there is no single benefit derived from FGM.

• Join the crusade to say “NO” to save the future generations of women.

• Enquire about the practice in your locality and give clear information and education to other people on the health effects of FGM.

• Work with other people to stop the practice in your area. Contact health or other influential authorities in your area to notify them about the problem.

• Discuss with your law makers or local representatives on making laws against FGM.

Support families and communities in their efforts to abandon the practice and to improve care for those who have undergone FGM.[15]

Conclusion

There is need for abolition of this unhealthy practice. A multidisciplinary approach involving legislation, health care professional organizations, empowerment of the women in the society, and education of the general public at all levels with emphasis on dangers and undesirability of FGM is paramount.

References

1. World Health Organization: Female Genital Mutilation: An overview. Geneva: World Health Organization; 1998.
2. UNICEF. Children’s and Women’s right in Nigeria: A wake up call. Situation Assessment and Analysis. Harmful Traditional Practice (FGM) Abuja NPC and UNICEF Nigeria; 2001. p. 195-200.
3. Odoi AT. Female genital mutilation: In Kwawukume EY, Emuveyan EE (eds) Comprehensive Gynaecology in the Tropics. 1st ed. Accra: Graphic Packaging Ltd; 2005. p. 268-78.
4. Adegoke P. Ibadan University Humanist Society. Female Genital Mutilation: An African Humanist view. November, 2005.
5. Asaad MB. Female circumcision in Egypt: Social implications current research and prospects for change. Stud Fam Plan 1980;11:3-16.
6. Hathout HM. Some aspects of female circumcision. J Obstet Gynaecol Brit Emp 1963;70:505-7.
7. Hosken FP. Genital and sexual mutilation of females. The hosken report. 3rd Review ed. Vol. 18. Vienna Published by Women’s International Network News (WINN); 1992. p. 4.
8. World Health Organization. Female genital mutilation. A joint WHO/UNICEF/UNFPA statement. Geneva: World Health Organization; 1997.
9. Senior Cordinator for International women’s Issues. Report on FGM or FG Cutting 2005. Available from: http://www. onlinenigeria daily news. [Last accessed on 2010 Nov 22].
10. Verzin JA. Sequelae of female circumcision. Trop Doct 1975;5:163-9.
11. Worseley A. Infibulation and female circumcision. A study of little – known custom. Br J Obstet Gynaecol 1938;45:686-91.
12. Akpuaka FC. Vulval adhesions following females circumcision in Nigeria. Postgrad Doct Afr 1991;13:98-9.
13. World Health Organization: Female genital mutilation. Fact sheet No. 241; June 2000. Available from: http://www.who. int/mediacentre/factsheets/fs241/en/. [Last accessed on 2008 Nov 2].
14. Yoder PS, Khan S. Numbers of women circumcised in Africa: The production of a total. Calverton: Macro International Inc; 2007.
15. WHO Elimination of FGM in Nigeria Plot 617/618 Diplomatic drive, Central District Abuja. Family Health Department, Federal Ministry of Health Phase II Federal Secretariat Abuja Dec 2007.
16. Mackie G. Ending footbinding and infibulation: A convention account. Am Socio Rev 1996;61:1009.
17. UNICEF. Overview of FGM/Cutting. Nigeria FGM/Cutting country profile. UNICEF Nigeria DHS 2003.
18. UNICEF. Changing a harmful social convention: Female genital mutilation/cutting. Innocent Digest. Florence: UNICEF; 2005.
19. World Health Organization: Health Population and development. WHO Position. Paper presented at the International Conference on Population and Development (ICPD), Cairo 1994. WHO/AIE 1994:/94 – 2. Geneva: Word Health Organization; 1994.
20. Kwame-Aryee RA, Seffah JD. editors. FGM In: Handbook of Gynaecology (A practical Guide to student and practitioners). 1st Accra: Max Associates Ltd.; 1999. p. 266-7.