Greater awareness among healthcare workers in Ireland is needed to help women who have undergone 'female circumcision', writes CATHERINE REILLY
A WINNING SMILE fails to conceal 19-year-old Amina’s* horrific burden, one that can render her bed-bound for days at the asylum seeker hostel in Co Galway where she lives.
Aged six, her family sanctioned a local “circumciser” in her native Somalia to mutilate her genitals, and the consequences reverberate across time and place and within mind, body and soul. When her period comes, it feels as though “the cutting” is happening all over again.
“Oh my God the pain, you are afraid of the pain,” says the teenager, her neat hijab framing a welcoming face. “I am like, ‘Oh my God, let it not come, let it not come’.”
She endures chronic stress, frequent infections, back pain and is anaemic, all likely traceable to that watershed day when she was mutilated alongside three other girls.
More than 2,500 migrant women in Ireland are estimated to have suffered some form of female genital mutilation (FGM) in their countries, according to AkiDwA, a national network of African and migrant women.
Social customs, control over female sexuality, marriageability and religion (although no faith obliges FGM) are commonly cited motivators behind a practice usually carried out by local women using basic items like blades and scissors.
FGM is most prevalent in Africa, with vast country-to-country variations: it’s very common in Egypt, Sierra Leone and Guinea, for example, yet quite rare in Cameroon and Uganda.
It involves partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons, says the World Health Organisation (WHO), which defines four main types.
The most common are type one – partial or total removal of the clitoris (an erectile part of the female genitals) and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris); and type two – partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are the lips that surround the vagina).
In Amina’s war-torn homeland of Somalia, it’s almost universal, and the majority suffer its most brutal form, infibulation or type three. This involves narrowing of the vaginal opening through the creation of a covering seal formed by cutting and repositioning the inner or outer labia, with or without removal of the clitoris.
When Amina feels intense pain, she takes painkillers prescribed for a back complaint, and suggests a reluctance to reveal her experience of FGM – which she terms “circumcision” – to medical professionals.
Her current GP in Galway is “nice”, she says, but Amina believes disclosure will result in being “told” to have her vaginal orifice “opened”. If she was later sent back to Somalia like that, her virginity would be questioned, she wouldn’t find a husband and would be a social outcast, she says.
“They wouldn’t buy my story if I said I just went to the hospital . No man would believe it, and I’d have to do it again.”
Many FGM-affected women in Ireland are reluctant to talk to healthcare workers, says Ifrah Ahmed (22), from Somalia, a Dublin-based woman who is a representative of the End FGM European Campaign led by Amnesty International Ireland.
In May, Ahmed organised a fashion show in Dublin to raise awareness of the procedure, opened by then Lord Mayor Emer Costello and attended by up to 300 people, many of them African-born teens.
“They want to get help but they’re scared of showing the doctor their private areas,” she says. “FGM is unusual in Ireland, so people will be shocked and you have to explain over and over. That’s what makes people say, ‘No, I don’t want to go’.”
According to Dr Andrea Scharfe Nugent of Dublin’s Coombe Hospital and course director of the MSc in women’s health at the Royal College of Surgeons in Ireland (RCSI), more awareness among healthcare personnel is needed and particularly vital in the obstetrical field.
“There needs to be awareness concerning which countries have a high rate of FGM in order that medical professionals would know to ask questions, and ascertain the type of FGM to assess their specific risk for delivery,” she says.
Nugent adds that a resource launched in January 2009 by the RCSI and AkiDwA, entitled Female Genital Mutilation, Information for Health-Care Professionals Working in Ireland, has proven "very popular in the Irish setting and internationally".
Funded by the Office of the Minister for Integration, it provides specialist information including expressions in English and native languages that women may use to describe FGM (a term unlikely to be used in itself).
According to the HSE, it will fund updated copies of this and is supporting the cost of a project worker at AkiDwA to “progress implementation of prioritised recommendations” outlined in a national FGM action plan.
So far, more than 500 health professionals such as midwives, GPs and social workers have been reached through training sessions financially backed by the HSE and previously by the Office of the Minister for Integration, while the HSE says it is developing patient information leaflets on FGM. Child protection is “strongly emphasised in all efforts” around informing women of the risks of the practice, says a spokesperson.
Meanwhile, the Department of Health says draft legislation specifically banning FGM is nearing completion. It will make illegal the sending or taking of children resident in Ireland to another country for the practice, a scenario not covered by the Non-Fatal Offences Against the Person Act 1997, which may also be flawed in terms of outlawing possible cases of FGM in Ireland.
No known cases of FGM have taken place here, but alarmingly, there appears to have been incidences of children being brought overseas for the procedure.
“We have heard of cases of girls being brought outside the country to have it performed,” says Sioban O’Brien Green, co-ordinator of the Migrant Women’s Health Project at AkiDwA. “What we have heard anecdotally is referring to Ethiopia and Nigeria,” according to O’Brien Green, who says these accounts involve “a very small number”.
It’s an issue that other western countries continue to grapple with, as underlined by a recent proposal by the American Academy of Paediatrics (AAP) for legal changes to enable paediatricians in the US to “reach out to families by offering a ritual nick as a possible compromise to avoid greater harm”.
The AAP withdrew this statement after critics accused it of supporting the “medicalisation” of FGM.
Amina, who would like to be a midwife or Montessori teacher, believes the key to unlocking mindsets is held by women like herself. She says she’d engage in dialogue on FGM within her disparate community in Ireland if a forum developed, and despite her own fears, says she wouldn’t allow any form of FGM to be perpetrated on her future children.
She believes those who sanctioned her ordeal will be called to answer – though not in this world.
“It is cultural, it is not religion, it is not in the Koran,” she says. “On the Day of Judgment, they will be asked about what they did to us. I can say, ‘Oh Mum, I forgive you’, but in God’s eyes, they are not forgiven.”
*Amina is not her real name
An online copy of Female Genital Mutilation, Information for Healthcare Professionals Working in Ireland can be accessed at akidwa.ie
FEMALE GENITAL MUTILATION: WHAT IS IT?
What is FGM?
FGM may entail full or part removal of the clitoris, labia minora and labia majora; narrowing of the vaginal opening; or other harmful procedures to the female genitalia for non-medical purposes, including pricking or scraping, according to the WHO.
Where does it happen?
It’s most common in the western, eastern and northeastern regions of Africa. It is also present in some countries in Asia and the Middle East and among certain immigrant communities in North America and Europe.
At what age is FGM usually inflicted?
Between the ages of four and 10.
Why is it practised?
There are cultural, religious and social factors. An Islamic context to certain types is argued by some, notably removal of the prepuce and/or even cutting of the clitoris, but this is highly contested. FGM predates contemporary world religions.
How many women and girls live with FGMs consequences?
Up to 140 million.
How many are now in Ireland?
More than 2,500. Most are from Nigeria, Somalia, Sudan (northern), Egypt, Kenya and Sierra Leone.
