The Culture Of Female Circumcision Health And Social Care Essay

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Advances in Nursing Science:

December 1996 - Volume 19 - Issue 2 - pp 43-53

Diversity In Health Care

The Culture of Female Circumcision

Morris, Rita PhD, RN

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Author Information

Associate Professor, School of Nursing, San Diego State University, San Diego, California; Faculty Member, School of Nursing, University of Phoenix, Phoenix, Arizona.


The issue of female circumcision takes on special significance as more women migrate to the United States from countries where the practice has religious and traditional underpinnings.Female circumcision is a problem unfamiliar to most Western health care practitioners. This article describes an ethnographic study of the types of female circumcision, the reasons for and against the practice, the health implications of this practice, and cultural attitudes of circumcised women both in Western Africa and as migrant refugees living in the United States. Ethical dilemmas in dealing with this practice and implications for nurses and health care providers are discussed.

The devastating clan and tribal wars in Somalia, with the ravages of violence, hunger, and famine, have claimed more than 100,000 lives since the ouster of President Mohammed Siad Barre in January 1991. Due to political unrest and continuous war, approximately 666,000 refugees left their homeland and escaped to the borders of neighboring African countries-Burundi, Djibouti, Ethiopia, Kenya, and Sudan-to live in refugee camps and await political asylum. [1]

"San Diego Somalia," as it is known in the refugee camps, has been a favored location for refugees assigned to the United States. In 1991, while San Diego received 425 Somali refugees, all other locations in the United States combined had only 492 refugees. Currently, the Somali refugee population in San Diego is estimated to be 3,000 to 4,000 and growing rapidly as refugees from other states move to join this community. [2] The majority of Somalis living in San Diego are Muslims and have many cultural rituals, including the practice of Pharaonic circumcision.

Health care providers with a Western orientation face many problems in serving this fast-growing Somali refugee population. Language barriers, the lack of trained interpreters, and a general lack of understanding of the strict African Muslim culture and, in particular, the practice of female circumcision, make caregiving very difficult. Many health care practitioners are unaware of the tradition of female circumcision among this population and respond with anger when initially confronted with it. The practice of female circumcision goes against the feelings and values of Western health care providers, who consider such practices barbaric and abusive.

This article seeks to enhance the understanding of Western practitioners about the lifeways of Somali refugees living in the United States by describing the history, culture, and traditional practices of female circumcision in African countries; reviewing the types of female circumcision and the health risks and gynecological and obstetrical complications, including medicolegal and nursing interventions to combat this dangerous practice; and describing Somali refugee women's attitudes toward enforced restrictions on the practice of female circumcision while living in San Diego. In addition, the article begins the development of a culture care theory using the ethnonursing method in relation to the practice of female circumcision. Data for this article are synthesized from the literature, the author's clinical and research experiences in Africa, a community needs assessment of Somalis in East San Diego, and case studies of Somali clients.

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The practice of female circumcision, also known as female genital mutilation (FGM), is ancient and found on all continents of the world. A Greek papyrus dated 163 BC made specific reference to female circumcision. The practice was more common among the Phoenicians, Hittites, Ethiopians, Arabians, Syrians, Malaysians, Indonesians, and Africans. [3] According to Toubia, "it is reported in at least twenty-six African countries that form a continuous belt across the northern sub-Saharan region, from Sudan to Senegal, and along the Nile valley from Egypt down to East Africa." [4] (p129)

Female genital mutilation is decreed by no religion. But it is passed on, generation to generation, and enforced by custom and religion. Nowhere in the Koran is female circumcision recommended. Wide variations among countries exist in the prevalence of FGM, ranging from 5 percent in Uganda and Zaire to almost 98 percent in Somalia and Djibouti. Estimates translate to about 6,000 girls circumcised every day. [4] It is estimated that at least 98 percent of all Somali women are circumcised and that 80 percent are infibulated. The term "infibulation" goes back to the Romans: "The Romans, to prevent sexual intercourse, fastened a 'fibula' or 'clasp' through the large lips of women." [5] (p15) These women were slaves, and infibulation was the method used to keep them from becoming pregnant so as to get maximum labor from them.

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Types of female circumcision

"Female circumcision" is a popular but medically incorrect term used to describe a variety of ritual surgical procedures performed on the female genitalia. [6] Generally, circumcision is done when girls are 4 to 8 years of age. [7] Three major types of female circumcision are practiced.

Sunna means following the traditions of the prophet Mohammed. Type I procedures, thought to be the type recommended by Islam, involve excision of the clitoral hood, with preservation of the clitoris itself and the labia minora. This type is recognized as circumcision proper.

Type II is excision, also referred to as intermediate. This procedure, referred to as clitoridectomy, involves the removal of the prepuce and glans clitoris together with adjacent parts of the labia minora.

Type III (infibulation, or Pharaonic circumcision) procedures involve removal of the entire clitoris, together with adjacent parts of the labia minora and the adjacent medial portions of the interior labia majora. The two sides of the vulva are stitched together (or stuck together with paste or thorns), obliterating the introitus and leaving only a small opening to allow passage of urine and menses.

The literature also describes a fourth type, which was practiced by the Pitta-Patta ethnic group of the Australian aborigines, requiring the enlargement of the vaginal orifice at puberty by surgically tearing it downwards or splitting the perineum with a locally fashioned stone knife. [5]

The propensity to circumcise females varies among different ethnic groups, and the type of operation depends on the religious and traditional beliefs of the people. Currently, according to all available sources, Type III circumcision is practiced only by Muslims in Somalia, Sudan, Mali, and northern Nigeria. [7]

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Attitudes toward female circumcision

A Westerner's outrage at the practice of circumcision was expressed by Hosken. [7] In the late 1970s and early 1980s, Hosken reported her findings at several congressional hearings and to international agencies. In her report, there is extensive documentation of the sexual mutilation of millions of girls and women that had been concealed for centuries. She noted that "from all the myths about the sexuality of men and women, none is more prevalent in Africa than the one that women are unable to control their sexuality, and are possessed by sex; hence, they must be excised or infibulated to preserve virginity and to save the family honor, or to protect the African family." [7] (p3)

Hosken [7] contended that changing customs, no matter how damaging, brutal, and irrational they may be, is very difficult. Attempts to abolish genital mutilation in Kenya in the 1920s and 1930s and in Sudan in 1940s failed. The failure was attributed to one-sided efforts that lacked political leadership, educational support, and organized campaigns. It was also before the radio was universally available in Africa, [7] and therefore it was difficult to communicate with large numbers of people.

Onadeko [8] studied female circumcision in Nigeria. His findings on women's attitudes toward female circumcision and their reasons for favoring or not favoring the practice revealed that women were proponents of the practice. A sample population of 453 women and 28 men were interviewed. Of the women in the study, 71.3 percent were themselves circumcised as children. The findings showed that 66.9 percent of females supported the practice, while 64.3 percent of the men disfavored the practice. Education had an impact on attitudes, with the more educated disfavoring the practice. A 90.4 percent majority in this study had less than a primary school education. Religion was also a factor influencing the practice; 70.3 percent of Muslims, compared to 29.7 percent of Christians, favored the practice.

Ebomoyi's [9] study of the prevalence of female circumcision in two Nigerian communities found similar attitudes among the 1,150 men and 1,150 women interviewed. The majority of women in the study were not only circumcised but supported the practice.

El Dareer [10] conducted an epidemiological study on the attitudes of Sudanese people in Northern Sudan, where Types I, II, and III of female circumcision are practiced. Detailed questionnaires were used with a sample population of 3,210 females and 1,545 males. The continuation of the practice was favored by five times as many women and seven times as many men. Notwithstanding this finding, the majority were against the most severe Pharaonic type.

Of great interest is a study of the views of future health care workers in Somalia on female circumcision. Gallo [11] studied a sample of 37 male and 58 female medical students and 144 female nursing students. The socioeconomic status of nursing students was lower than that of medical students. Fully 97.2 percent of the female nursing students and 62.1 percent of the female medical students were themselves infibulated. Attitudes toward maintaining the practice were overwhelmingly positive for female nursing students, with 90.3 percent, compared to 13.8 percent of medical students, advocating the practice. The attitudes of these future health workers are widespread in their culture, but it is surprising that future nursing students could be strong supporters of a practice so hazardous to health. Perhaps the lower socioeconomic status of nursing students accounts for their differing attitudes.

It is clear from these studies that the practice of female circumcision is deeply rooted in many cultures. Girls grow up knowing that circumcision is essential if they are to some day be considered fit to marry, find a man willing to marry them, and raise a family.

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Several researchers, including Johnson and Rodgers, [12] Kluge, [13] Milos and Macris, [14] and Hosken [5] have identified both favorable and unfavorable reasons for the continuance or discontinuance of this age-old ritual. The following discussion summarizes their findings.

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Reasons for

The practice is part of cultural heritage and tradition. Rightly or not, many Muslims believe that Islam favors or even requires the practice. Mothers also assert that because they were circumcised is reason enough for their daughters to be circumcised. Even those who do not favor the practice may face overwhelming social pressure from other family members.

Circumcision dampens sexual desire and vulnerability to sexual temptation. It is believed that if the clitoris is left to grow, it will increase a woman's desire to have sex; hence, its removal will subdue a woman's response. It also believed that sperm could contaminate a nursing mother's milk and harm the baby. Therefore, for the 18-month breastfeeding period, the mother abstains from all sexual relations. The sexless life is considered more tolerable if she is circumcised.

The practice prevents promiscuity and maintains virginity. In agrarian societies, where young girls tend cattle and go long distances to fetch water, infibulation is considered a safeguard to protect the family honor. The practice also has economic implications: The father gets paid the bride price for a virgin, and the evidence of virginity is infibulation.

The practice ensures fidelity in a marriage. Reinfibulation after childbirth is a means to ensure that the woman remains faithful.

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Reasons against

Female circumcision is a barbaric traditional cultural practice of the past that leads to medical complications, including infection, hemorrhage, and even death.

The practice is a human rights and child rights violation.

Complications during marriage and labor include severe bleeding, interference with orgasm, permanent emotional damage, tetanus infection, complications in childbirth, keloid formation, rectovaginal and vesicovaginal fistula, endometriosis, infertility, rectocele, and incontinence. In addition, the procedure results in the denial of a woman's self-fulfillment by grossly reducing her sexual pleasure.

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Ethnonursing research methods [15] were used to systematically document and gain greater understanding of the meaning of people's daily life experiences. These methods were useful in studying the lifeways of the people, getting to know them, and learning about their problems, fears, and concerns. Successful techniques for eliciting information included.

???speaking to women's groups without the presence of the men. Custom usually dictates that men should answer questions put to women, often without consulting them.

???keeping an open mind and using a friendly, relaxed, and nonaggressive approach, cultivating and showing genuine interest in listening to the women, and carefully heeding intuition and terminating all interactions promptly if informants seem uncomfortable.

???showing sensitivity and responsiveness to ideas expressed and encouraging informants to tell stories of their life experiences, daily happenings, cultural beliefs, values, and life expectations.

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Two African countries where the practice exists were included in this study. Liberia is a country in West Africa where the rituals and tradition surrounding the practice of FGM abound; female circumcision is restricted to Types I and II. This study included a major tribe, the Kpelle, who have rituals and practices that are kept secret and are not openly discussed. The Poro society, a secret society of the Kpelle tribe, runs schools for prepubescent boys and the Sande Bush School for girls. The School is held every 3 or 4 years, depending on the abundance of the crop harvest.

In western Kenya, 10 girls were interviewed; all were participants in a nutrition and family planning project funded by the United Nations Children's Fund. They were between the ages of 16 and 18 years and had a high school education.

In the United States, a group of five undergraduate nursing students studied, under faculty supervision, the Mid-City section of San Diego, where about 2,000 Somali refugees live. This community needs assessment project included interviews and observations of Somali families, from which the study data were gathered.

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Data analysis

The data were collected during the early 1980s in western Kenya and in the late 1980s in Liberia. The author had many unique experiences while working in East and West Africa in advisory and consultant roles implementing primary health care programs. Detailed community needs assessments were conducted in both countries, which provided access to attitudes and the practice of FGM. In the United States, the data were collected in the spring of 1993.

Leininger's [15] ethnonursing methods, focus on active listening and reflections, descriptions, participant experiences, and data derived from open-ended inquiries and were the methods of data collection used. Detailed notes of the interviews and field notes of observations were maintained. The combined process of reflection, imaginative thinking, and systematic sifting and analysis of evidence culminated in the synthesis of data and abstraction of meanings, resulting in credible and understandable conclusions.

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The Liberian experience

The practice of FGM is shrouded in secrecy and ritual. In Liberia, the Kpelle tribe prepares for the Sande Bush School every 3 or 4 years. A tall fence is built at the edge of a town, and the tallest Sande drum is set up near the fence. Women take charge. When all the preparations are made, the tall drum booms out its invitation, and all the young girls between the ages of 9 and 15 years are chaperoned into the forest to start their training in the arts of womanhood. Currently, the training ranges from 6 weeks to 3 months.

The Sande Bush School is similar to a finishing school for young girls. All adult women of the tribe must belong to the Sande Society. This society is responsible for the initiation of young girls to womanhood. They are taught the art of being good wives and mothers and how to cook and care for men and babies. Sometime during this period of initiation, the zoes (people with supernatural powers used for the good of the community) circumcise the girls. The procedure is done under unsterile conditions, and resultant infections cause the deaths of some of the young girls. Because these rituals are secret, getting accurate data about these practices are difficult.

At the end of the Sande Bush School, rituals and festivities mark the girls' rite of passage. The whole village participates in the festivities dressed in colorful symbolic clothing. Amid music, dance, and song, mostly performed by the men, the young girls are brought out of the school to enter into a new phase of their lives, the passage from girlhood to womanhood. The girls, dressed in their finest clothes, walk bent to the waist, looking at the ground. Their faces are decorated with white chalk, and their hair is beautifully dressed with ornaments and braids.

All the families bring gifts, except for those whose daughters died during their initiation. A broken pot on the door step the night before signifies that the daughter from that home will not return. No one is permitted to mourn the death of the young girls on the day of rejoicing. Later, these mothers will be helped to mourn and accept their loss.

The deaths of young girls submitted to female circumcision at these bush schools under secret societies are accepted and explained as the blessings of the ancestors. The question arises how such incidents could be prevented. In Liberia, the staff of one Christian hospital decided to intervene. After negotiating with the tribal leaders, permission was granted for Kpelle doctors and nurses secretly to perform the rituals in the forest. This was a successful example of "culture care accommodation" [15] (p42) between the community and the hospital.

The hospital team performed the Type I procedure in a mobile van. This strategy was successful in reducing the mortality rates. It was viewed as a transitional measure until the practice could be re-examined by tribal leaders and accepted as a practice harmful to women. Until then, the Western practitioners felt it would save more lives to do the surgical procedures.

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The Kenyan experience

Questions centering on attitudes toward female circumcision revealed that all the respondents were very adamant in their support of the practice. They believed it was their tradition and that no one had the right to tell them to abandon it. Type I circumcision was the method of choice. They were very proud of the practice and felt strongly that it should be continued. Pain was viewed as an essential part of life, a toughening experience in preparation for motherhood.

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Community needs assessment in East San Diego

Somalia is a Muslim country, and the Somali refugees in San Diego have brought their traditions and religious customs with them. At the Winona Avenue mosque, used by a majority of the Somalis for their daily activities, classes are offered daily to study the Koran. Somali women cover all of their body except their face and hands; their traditional headgear, or hijab, shows that they are faithful to the Islamic teachings. They are very cautious about associating with men. The Muslim faith requires that prayers be conducted daily at five specific times, wherever the adherent may be. Part of the ritual involves washing their feet, and this religious practice caused a problem at the Mid-City adult education center, where some washed their feet in the public bathrooms.

The family is the most important social system in the Somali culture. In Somalia, the extended family structure is a political as well as social unit. Families form tribes according to ancestral relationships and common interests. The members of the tribe are expected to support and help each other. Decisions involving the entire tribe or conflicts between tribes are settled by tribal elders. The father is the head of the household, and the mother is the care provider. Girls in Somali families are expected to help their mothers around the house from about age 7, and are considered mature and responsible after age 14. Boys do not perform household chores and are considered adults at 15.

In the United States, the Somalis must deal with changes in family roles and expectations. A significant difference is the position of the women in the family. Women are finding it not only socially acceptable to work, but also financially necessary. Outside the home, they are trying to conform to American society; this is a major stressor. They value education for boys, but here adults, both men and women, are taking English classes, and girls are sent to school. In the beginning, the girls were veiled and wore their own traditional dress, but now elementary school children are wearing blue jeans with dresses as tops.

Islam teaches the importance of having children, and the belief that Allah will provide for the parent and child is unquestioned and very strong. Abortion is forbidden under any circumstances, and contraception is not commonly used. Breastfeeding is believed to be a form of contraception, as no sex is permissible for the period of breastfeeding. However, breastfeeding has been abandoned for formula feeding and many Somali women bear children every year. The large family size is condoned. It is not uncommon to find women with 9 to 10 children.

Changing attitudes toward family planning were observed among a few couples. These were the acculturated educated couples, who acknowledged using birth control because large families were prohibitively expensive in the United States. Such decisions were discussed and jointly made by the couple.

All the Somali women interviewed had Type III circumcision. Most of them had the procedure performed surgically in hospitals at the ages ranging from 5 to 10 years. A few were aware that although it is a traditional practice, it is not mandated in the Koran or other Islamic scriptures. Most women firmly believed that the practice is dictated by their religion. Many women could not understand why physicians or midwives in the United States and Canada will not perform this procedure.

Many of the Somali women expressed a fear of Western obstetricians and midwives. They felt that Western practitioners have no experience in dealing with infibulated women. They insisted on reinfibulation after delivery, because they feared their husbands would divorce them if they were not reinfibulated.

One informant reported that her friend had severe complications with the infibulation. A doctor opened her and removed scar tissue and felt that it was important not to reinfibulate her. He gave her a written report of the treatment performed. However, when her husband returned from work out of town, he was very angry with his wife and divorced her.

The assessment indicates that the Somalis in San Diego view circumcision as an integral part of their heritage, culture, and tradition. They strongly support the practice and are anxious to have the procedure done for their female children. Some women told us that being circumcised and infibulated is hygienic. The words of one respondent best describe the sentiment: "Whoosh! The lumps are gone. It is smooth and clean. The stitching is like the zig zag stitch, so beautiful."

However, the procedure is not readily available in the Western hemisphere, and most Somalis lack the funds required for a trip back to Africa to have their daughters circumcised. Genuine distress results, including guilt and fear that their daughters may not be able to get married to Somali men.

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The findings show that most Somali women living in the United States are very frustrated that they cannot have their daughters circumcised. They are aware of the illegality of the procedure in California. The state legislature is also considering the introduction of Assembly Bill 2125 making it a felony to perform the act or to allow FGM of one's child under 18 years.

The dilemma that faces health care providers is whether the failure to perform the procedure will harm a woman's self-esteem and cultural identity or affect her social integration. However, what makes FGM special is the fact that it is a decision usually made by a woman on behalf of a child. There is no doubt that it is unethical for a health care provider to perform female circumcision. It is misplaced cultural sensitivity to perform procedures known to be medically inappropriate, harmful, and demeaning: "No one has a duty to do something that is unethical. This is not a matter of personal values but of basic, universal and fundamental ethical principles that apply to all people." [13] (p289)

The complexities of the issue can no longer be ignored; the population of the United States is becoming increasingly diverse, and immigrants and refugees import their practices and culture. Article V of the United Nations Declaration of Human Rights states, "No one shall be subjected to torture or to cruel, inhuman or degrading treatment." Is it torture or cruel or inhuman treatment when the victims perceive it differently?

Anthropoligist Anke Van Der Kwaak's caution in dealing with this very complex issue is well worth pondering: "Although we in the West may have sincere intentions in this matter, we should be careful not to march to the sound of a drum Somali women cannot hear. The web of strands, in which infibulation is entangled, is so complicated that no short term remedies are feasible." [16] (p785)

Toubia [17] confirmed that cultural identity is a very strong force and that it will take time and new information for people to abandon tradition.

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Nurses and health care professionals need a better understanding of the cultural factors supporting female circumcision. To this end, curricula and continuing education programs for health care professionals should provide the facts and explore the ethical and counseling issues concerning female circumcision. Better understanding of this subject may lessen the hostility that Western health care providers too often feel toward women who consider circumcision a vital heritage, and not an outmoded and barbaric abuse.

It is important for health care providers alien to the culture of FGM to become familiar with this culture and to actively participate in policy decisions and legal issues affecting a population in transition.

It is crucial for health care providers to be advocates for young girls whose mothers effectively consent to the procedure on their behalf. Effective advocacy requires understanding the values and viewpoint of the mothers.

Support groups for women who do not wish to have their daughters circumcised need to be organized. Successful tactics for resisting pressure from elders and religious leaders need to be explored and implemented. Discussion groups, including mothers and fathers with their community leaders, could facilitate the search for viable alternatives.

Laws alone will not bring about cultural change, but education and greater economic independence for women will facilitate acculturation. Framing FGM as abusive or illegal may not bring about the desired changes; agents of change must come from within a culture. [18]

Working together with the Somali people to discourage harmful practices must be a priority in the transition period. Once the act is performed, it cannot be undone. Pilot programs for the implementation of successful strategies need to be planned, funded, operationalized, and evaluated.

Circumcised adolescent Somali girls in high school are particularly vulnerable to experiencing sexual identity problems, as they are in social settings where their peers are different. Anticipatory guidance will prevent serious future mental health problems.

The pursuit of interdisciplinary research using grounded theory methods may lead to a viable theory for practice. It is necessary to involve members of the interdisciplinary team, doctors, community and school health nurses, midwives, ethicists, social workers, counselors, and refugee management workers. This age-old custom will require the collaborative and coordinated efforts of all the players to build successful theories for practice. The time is now. The harm done is irreversible, and prevention must be the operative strategy.

It is clear that female circumcision, steeped in ritual, is an ancient practice, yet it survives among the Somali Muslims living as refugees in the United States. Given the pain and risks associated with this practice, health care providers need to direct their efforts to the task of untangling this very complex web. From a modern Western perspective, it is extremely difficult to comprehend a culture where a women seem to condone abuse and accept subservience to men. Yet this challenge must be approached with understanding, patience, and dialogue in order to find alternatives to female circumcision among the young girls now living in the United States. We need an objective assessment of the problem and more research to understand how to help people steeped in rituals and tradition bridge the gap to a way of life that will protect their health. Such studies will lead to the development of a theory to deal with cultures in transition. We need to strike a delicate balance, accepting diversity yet promoting change at the same time.

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