Globally, almost 200 million women and girls are living with scars of Female Genital Mutilation (FGM) inflicted because of gender violence and imbalance of power (World Health Organisation, WHO 2018). In Egypt alone, 1 in 5 of the girls under the age of 5 is mutilated (Costello 2015). Research tells us that 66,000 women in the UK are estimated to have been mutilated and furthermore, about 20,000 of girls living in England and Wales are at major risk of this violent practice (Simpson et. al., 2012; Public Health England, PHE 2016). It is therefore important to critically analyse the impact FGM has in relation to health and well-being of women and girls and on health services. The approach shall analyse the perceptions that lead to this harmful behaviour, as well as the public health response since the Home Office (HO 2013), referred FGM as a hidden crime. Furthermore, the essay will precisely consider the use of a theory that best explains this debilitating behaviour.
The World Health Organisation in 1996 defines violence as “the intended use of physical power or force against oneself or another person or a group or community resulting in injury, death, psychological harm or deprivation” (WHO 2018). With reference to FGM, it is a form of violence against women subjected to the dominance of cultural norms and power imbalance in countries that include the Middle East, some parts of Asia and the central African region (Peltzer and Pengpid 2014). Nonetheless, The Home office further to refer FGM as a hidden crime associated with physical torture to children (HO 2013). It is therefore undeniable that FGM requires public health response as it involves physical violence to defenceless girls and young women.
On religious perception, there is strong evidence that suggests people perceive FGM as obligated by the Islam. However, Kontoyannis and Katsetos (2010) disagree and points that, FGM is not stated in the Koran and therefore not an Islamic belief instead it is practised by Muslims. Nevertheless, what perpetuates the practice is clear gender-based violence against women and girls. Since FGM has become a global concern that affects individuals and health services hence – public health intervention is required.
How to measure this debilitating form of violence it is complex. Nonetheless, the research conducted by Griffith and Tengnah (2008) gives us a picture how the World Health Organisation categorized FGM into four different types. These types classify the harshness FGM has on each level. There is the procedure that consists of partial removal or complete removal of the peripheral female genitalia or some genital organs (WHO 2018). Another one is the clitoridectomy that consists of the removal of the entire clitoris and the labia. The excision entails the removal of the tip of the clitoris and infibulation is the extreme one. The last one involves the two forms whereby the vagina is stitched up leaving a tiny hole for urine and blood to pass through. Convincingly, Sihwa and Baron (2004), argues that “the very organs that allow humans to reproduce are mutilated for no benefit to the victim”. The whole procedure indicates that there is no empathy given to the vulnerable girls and women as the motive is not in the victim’s best interest.
In addition to the above, Cox (2017) sees the practice as a correlation between child abuse and a form of sexual violence that should be morally and ethically intolerable. In addition, the qualitative work by Costello (2015); WHO (2018) and UNICEF (2016) points that this ferocious and unbearable practice lack medical explanation and instead, it encompasses sociocultural and religious beliefs that correlate with inequalities against gender. Further to that, Manderson and Bennett (2003) stress that FGM is a violation of human rights to victims and has become a multifaceted global problem. This is because developed countries that include the UK have FGM prevalence with new incidence occurring and these are mainly patterned by migration (Forward 2016).
It is important to have insights about risk factors when addressing FGM as a form of violence. Girls and women are susceptible to FGM and the reasons are differing. It is noted that the causes for this human right violation include beautification, virginity, virtue, femininity, and most importantly social inclusion in FGM communities (WHO 2018). Nonetheless, women and girls pay the price for those expectations unwillingly and the risk they encounter is a perfect example of ignorance because of a primitive culture that started over 2000 years ago (Inungu and Tou 2013). UNICEF (2016) tells us that the major risk factor is that, FGM procedure encompasses the use of tools that are hardly sterilized. This includes knives, razor blades, scissors and in some case broken glasses. Evidently, the risk for transmittable infections such as HIV is high. Although some countries such as Egypt are diversifying to healthier FGM procedure by ensuring that process is done in a clinical environment. UNICEF (2016) points that in Egypt, more than half of mutilations are performed by qualified nurses and physicians privately (Cox 2017. Conversely, in many countries, FGM procedure is still carried out by unprofessional community female elders putting the lives of vulnerable girls and women at increased unbearable torture and health risk such as death.
There are severe immediate consequences with FGM according to the UK Home Office (HO 2013). Death can be encountered as soon as mutilation process. In addition, they are short and long-term physical risks that include difficulties in urinating after the mutilation process, haemorrhage, cysts, pelvic infection and complication during maternal health (Bell 2008); (Andros, Cambois and Lesclingand 2014). Additionally, Costello (2015) and Diana (2007) both research finding agrees that risk factors also include both short and long-term physical and psychological health consequences. Despite, Daley (2004) stresses that women end up believing that it is how they should live their lives, “to be victims”. While focusing on cultures where women are socialized to please man, sociocultural morals built barriers to power relations between men and women. It is, therefore, the women who suffer the consequences. The evidence further suggests that they suffer in silence and struggle emotionally and physically (Kontoyannis and Katsetos 2010). Therefore, for a public good, girls’ health should be protected in order to eliminate the suffering. This is because they lack the power to protect themselves as this torture mainly happens while girls are still young.
With a focus on how FGM impacts victims, there is rich evidence that suggests survivors face complications in childbearing. Health risks for survivors are always prevalent as long as they live and the impact on childbearing is immense on mothers and the unborn children. Mortality rates are high and even infertility (Utz-Billing and Kentenich 2008). A research evidence in African study suggests that in a 1000 births, 10 to 20 new babies die during delivery (WHO 2006) and those with type 3 FGM have 55 % higher mortality rates. Pollard and Hyatt (1999) elaborate that FGM affects the success of maternal as well as perianal health and influence the likelihood of the cumulative of chronic diseases and as a result costing the health services. Further to that Kontoyannis and Katsetos (2010) states that women who have undergone FGM require special care to accomplish improved childbirth. Lavender, Baker, and Richens (2006) agreed to the sentiments and went on to suggest that this is a burden to government taxpayers and health services.
FGM is illegal in the UK and in other western countries. However, migration and resettlement for FGM survivors and those who still practice and believe in this violent behaviour are influencing prevalence and incidence resulting in a huge impact on health services in the UK and globally. There is a limitation of published evidence about health problems associated with FGM nonetheless, Simpson et al., (2012) points that it is the under-reporting that contributes to the little evidence published.
In 2015, almost 5,702 women and girls were treated by the National Health Services (NHS) because of mutilation and 106 of these patients were women under 18 (Bennett 2016). Health care services also face further challenges based on “Person-centred Care Approach” as this increase the costs of translators and at the same time learning to understand cultural values and counselling. According to Ball (2008), the NHS has increased protocols on caring for FGM victims due to the rise of child delivery bookings. In the past few years, they have been 10% increase so to maximize the care and support. Nevertheless, the impact of this violent behaviour on health services in the UK is a challenging one and to other nongovernmental organizations in order to engage in programmes tailored to improve and maintain the health of the communities at risk.
Within the public health concept, special care is vital to victims of FGM. These include improved services for maternal health. Currently, there are only 13 health services that specialise in maternal health in the UK. This includes Birmingham Heartlands Hospital that offers midwifery services for women who have undergone FGM (Ball 2008).
Although they are stages to measure the FGM severity that has been discussed earlier, however, there are theories developed to promote the understanding of social dynamics that gives an explanation to different types of violence including FGM. These are constituted by individuals who engage in collaborating strategic engagements needed in the development of empowerment, socially inclusion, tackle violence and promote equalities (Radford, Friedberg and Harne 2000). However, to determine a theory that best describe factors that perpetuate FGM among families it is complex because we need to have a deep understanding of this brutal practice. Feminist perspective might be put into context nonetheless, the theory examines women’s social roles and their life experiences hence to enforce the obligated opinions on how the factors that perpetuate impacts women’s health in every sense. With FGM, the best theory will comprise the combination of variables such as culture, ethnicity, religion, and marriageability as these are the factors that propagate this violent behaviour.
Shell-Duncan et al., (2011) state that for parents to diverge from FGM they fear exclusion in their communities. Shell-Duncan and colleagues, however, acknowledged the Social Convection Theory. This was developed in 1960 by Schelling to address foot binding in China which is also a violent behaviour similar to FGM in a sense that it involves the brutal act that correlates with sociocultural influence. Social Convention Theory gives us insights why families choose harmful practices to their children (Shell-Duncan et. al, 2011). In addition, the theory aims to promote health and well-being of the public through enforcing education and promote awareness that empowers change to the practice.
Contrary to the above, there are situations whereby this philosophy will be inevitable if the behaviour is having cultural and political acceptance (Jenkins 2002). For instance, in Asian communities’ gender norms and discrimination among women who are marginalized and exposed to extreme poverty are likely to have social injustice (Manderson and Bennett 2003). Same again in Bangladeshi where acid violence is more prevalent in women and perpetuated by the context of political and cultural norms (Mannan et al., 2004). These actions increase gender imbalance and risk to violence. It is therefore important to use the Social Convention Theory as it is tailored to promote the transition of social fairness.
Adding to the above, Shell – Duncan (2011) suggest that, based on the perception of cultural norms whereby women have the moral obligation to respect desired outcomes from elders and societal beliefs there is a limitation within the theory as it fails to facilitate peer and social networking. According to Bandura, sociocultural influences in broad networking produce products of the social system (Bandura 2001). Furthermore, theories that examine sociocultural situations should account for social interaction and this should be meaningfully structured (Habermas 2002). The strategy to direct social networking that is intergenerational in efforts to eradicate FGM should include both men and women to help and reinterpret social convection theory. This is when addressing FGM as a form of violence and public health response.
The Home Office (2013) claim that gendered pattern of violence against women and girls need a deep understanding and to consider precautions on how to protect them. In 1997 the World Health Organization in partnership with the United Nations Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA) delivered a declaration in the paradox of violating children’s lives through FGM (WHO 2018). The document highlights the increase of human rights and the ambition to eradicate FGM. The guidance generates the causes and consequences of the practice with the ambition to eliminate and care for the victims. Furthermore, the joint venture urges professionals not to take part in this violating behaviour towards children. Yet again, the United Nations Convention on the Rights of the Child (Amnesty International 2010) claims that FGM is one of the worst violations in children. The consequence it has in public health concept is major in terms of costs incurred to tailor the best care to the victims. Therefore, UN issued a zero tolerance for FGM to halt this violent practice by the year 2030.
In the UK efforts to curb FGM is in the public health domain. In circumstances where a girl’s protection is of need, the Human Rights of the Child (article 3.1) state that, “interest should be undertaken in their best interest” (Amnesty International 2010). Back in 1996, the study on combating FGM notes that the elimination will have a better outcome on health and well-being of women and girls as well as promote gender equity (Dorkenoo 1996). The UN strategy in combating this practice is based on social mobilisation, community-based intervention through educating and training volunteers, teachers and midwives in countries clinging to this harmful behaviour. Currently, in Ethiopia families are embracing behavioural change through the involvement of NGOs campaigns (UNICEF 2009).Therefore, adapting to multidisciplinary action with the interagency coalition in efforts to eradicate will mean that there is compliance with human rights and that women’s health and well-being is safeguarded. Although some countries such as Egypt is diversifying to a healthier practice to minimize the risk of infections, deaths and reduced physical and psychological pain (UNICEF 2016) however, the procedure is still unjust.
Conversely, in order to safeguard children’s health and their well-being, the UK government require those who work with women and girls to be the first responders (Bennett 2016). The government set a number of strategies and interventions designed to protect children vulnerable to all forms of violence. A good example is a scandal reported by Waterhouse Report whereby children were physically and sexually abused. Although this is not FGM however, the government accepted the 72 recommendations set by Sir Ronald Waterhouse (Waterhouse Report 2002) in efforts to fight child violence. Following to that, the government also agreed to the 5 key principles recommended by Lord Laming in Every Child Matters Act in response to the case of Victoria Climbie`. In 2003 the implementation of the Female Genital Mutilation Act in the UK was applied to regulate the abandonment of FGM to UK citizens. It also gives all professionals that work with children and public health community the responsibility to protect vulnerable girls at risk for mutilation (British Medical Association, BMA 2015). These strategies are needed to safeguard vulnerable children. This is despite that, some countries such as Sierra Leone argues that FGM is not a harmful practice.
Despite all the above interventions, legislation and regulations, implemented to support girls at risk for mutilation, Sihwa and Baron (2004) point out that some health professionals are continuing with this prohibited practice and surprisingly without punishment. The debate in the House of Commons also raised same concerns. British Broadcast Cooperation, BBC (2016) in support reported some areas of failures that include lack of convictions being made despite a number of years since the practice was made illegal. The Commons committee elaborate by reiterating that FGM is becoming a “National Scandal” because of new incidence believed to have taken place to British citizens and the committee agreed to make stronger sanctions by tightening the law (BBC 2016).
Contrary to the above, the lack of reliable data and poor prosecution and convictions is a result why the problem persists (BBC 2016). Evidence shows us that between the period of 2015 and 2016 almost 5,700 new cases recorded in England and campaigners criticise the lack of FGM education in schools (BBC 2016). Home Office (2013) agreed that violence against women and girls in developing countries is often endemic and significant; however, the society that is supposed to enforce change does not expect the government to intervene to their customary inheritance. Nonetheless, countries such as Ethiopia and Sierra Leone, in particular, have zero tolerance for anyone standing up against the abolishment even the government hence – behavioural change intervention becomes complex to influence change. It should be a pivotal role for men in taking steps in the abandonment of FGM and educating society is also essential (Varol et al 2015). Therefore, in order to promote and encourage interventions and strategies on a global level to communities with the FGM ideology, strong partnership-approach that set effective educational measures on a cultural level is required.
FGM is a violent practice with major health concerns. It is indisputable that even though the mutilation is to honour the families or to satisfy men’s sexual pleasure, victims carry the mutilation scars through the course of their lives. This affects their health and well-being. Additionally, society suffers as well. This is in terms of prioritisation of health costs. FGM survivors require specialised maternal care and this incurs vast sums of money to care for them. As a result, it is the role for public health movement to take a role in the fight to abolish FGM. The UK government urged Schools, health professionals, and general society to report any signs of abuse and violence to promote health and well-being, especially those exposed to this risky behaviour and vulnerable. There are guidelines published by the home office to tackle this criminal offence. Organisations such “FORWARD” also play a public health role to safeguard the rights and dignity of those at risk of FGM in the UK and abroad. It also supports the abolishment of FGM. However, lacking compliance with protocols will worsen the situation and keep on impacting public health. It is therefore important for Effective and efficient measures are important in efforts to eradicate this brutal practice and promote equality.