Protecting daughters from primitive rites
IT IS an image that for many in the Western world is deeply shocking. Girls held down in primitive conditions while a traditional midwife uses a knife, razor or scissors to cut their genitals, with nothing to dull the pain.
For some it is a rite of passage into womanhood and a way of ensuring virtue by controlling sexual desire. But for many who have undergone the procedure it is an unnecessary mutilation that can set the scene for a lifetime of health, social and emotional problems whose effects spill over into work and family life, complicating childbirth and sometimes destroying marriages.
"I had a woman in here the other day who had it done when she was six," Royal Women's Hospital midwife Maxine Reid said. "She was taken out bush and held down while they did it with no anaesthetic and she could tell me graphically, it was imprinted in her mind, how the old woman who did the job picked up the bits and pieces that she had cut off and said to the mother, 'Is that enough?' And the mother said, 'No, take off more'."
In Melbourne, female circumcision has its most obvious impact in the stream of women, many arriving as refugees from African nations such as war-torn Somalia, turning up at hospitals for care during pregnancy.
In the most severe cases, the labia minora (inner vaginal lips) and clitoris are cut and the raw edges stitched together to narrow the vaginal opening. In Melbourne, doctors and midwives reopen a woman's vagina so she can safely give birth. Without First World healthcare the baby may be unable to pass through the birth canal, causing a woman to lose her baby and her life.
Doctors can reopen the vagina while a woman is in labour, but it may be more comfortable for her to have the procedure earlier in pregnancy. Aside from the risks to a girl at the time, including severe bleeding and trauma, female genital mutilation can also cause long-term health problems such as infections, pain and nerve damage. Melbourne hospitals see women who complain of infertility, but it turns out they have never been able to have sex.
In response, the Royal Women's Hospital two years ago set up Australia's only clinic to reverse the vaginal narrowing, known as infibulation. They have since seen 83 women for consultations, and de-infibulated 25 women aged 18 to 57.
The hospital sees hundreds of women each year who have had some form of female genital mutilation, but the clinic only deals with the most severe cases. At the lesser end is a "ritual nick" or minor incision of a girl's clitoris. Reid said most of the women seen by the clinic had a "type two" circumcision in which part of the clitoris and labia minora was removed and the raw tissue fused together to narrow the vaginal opening.
In the worst cases, "they've removed everything and sewn them up until there's only a little opening", Reid said. "Even consummating your marriage is difficult.
"The problem with some girls we are seeing in the clinic is that it is so tight, and so uncomfortable for them to have sex, they don't want their partner near them."
Before the clinic was established, women would either present in labour or face long waits to have the procedure done by a gynaecologist. Other Melbourne hospitals also provide support services, including deinfibulation, but the Women's is unique in having a dedicated clinic run by midwives. At the Women's, a midwife now performs the procedure in a consulting room an hour after the woman has applied a local anaesthetic cream at home.
"We put a local anaesthetic up the suture line and we snip it open until it goes to just above the urethra, where a woman is normally open to," Reid said.
"We can't put back what's been removed but we can try and open them to a decent shape and then just oversew the edges so they don't come back together."
Among the women who have attended the clinic is Samah*, 36, who came to Australia a decade ago after growing up in Sudan. When she was seven her grandmother arranged for a woman to circumcise her, along with younger siblings, at home in an event that stretched out for days and culminated in a feast.
Samah, who is studying and taking care of her young son, now has mixed feelings about the practice. At the time, she was caught up in the excitement of the ritual, but it has caused problems for her in adult relationships. "I remember I was happy, I had a nice dress and they did henna [tattoo] for me," she said.
"I do remember the pain, but I was surrounded by loved ones, so I think I associate it with the people I care about rather than the procedure.
"Maybe other girls were forced, but I remember my grandma touching my hand and saying it's good for you, and I trusted her because of the connection we had."
Samah said being circumcised helped her when she went overseas in her 20s, "for me not to have that physical attraction to men, I think it protected me in protecting my family name".
She said it was a barrier to intimacy, but "some young males want girls who have had it done because for them it's about control. They know she is a virgin and doesn't need sex."
For Samah it was a surprise when she became pregnant to a man she met after moving to Australia. "We tried to have sex, but it was difficult so we stopped. The doctor said sometimes pregnancy can happen, even if you don't have proper sex, because there is a lot of sperm there."
She attended the deinfibulation clinic after having a caesarean birth, in a bid to improve her relationship with her son's father. "I had the procedure to be able to go back and be with him, but I haven't. It's complicated my life in a way because I have no excuse for not going back to the relationship. I'm still trying to work it out."
The clinic can refer women to various specialists, including physiotherapists and sexual counsellors, to help them with some of the difficulties.
Midwife Marie Jones said women seen by the clinic are often accepting of what has happened to them but do not want others to suffer their fate.
"We see a lot of very educated women who have had relationship problems that have obviously stemmed from this practice. They've been married to a lovely man and because of sexual difficulties their relationship's broken up. One woman came to have it reversed because she had divorced her husband and she really wanted to get back with him.
"Then there are the young women in their late teens and early 20s who can't believe what their bodies look like. They've seen a supposedly normal vagina and vulva and then they look at themselves and they are so upset.
"These are women who are not sexually active yet, they are coming up to that, and I suppose they are thinking, 'Well, what's it going to be like?"'
Multicultural Centre for Women's Health executive director Adele Murdolo said it was important to provide good healthcare to women who were subjected to female genital mutilation as children, and work with them to prevent it from occurring in the next generation. "The women I speak to say, 'We had it done to us and we didn't have a choice, but we're not going to do it to our daughters'," she said.
Laws were introduced in Victoria in 1996 making it an offence to perform female genital mutilation, or to help anyone else perform it. They prevent anyone from circumcising a girl or woman, including removing or stitching any part of her genitals for cultural reasons. It is also an offence to take someone outside Victoria for the purpose of female genital mutilation, with jail terms of up to 15 years, so parents or grandparents cannot have it performed on children during a visit to their country of origin.
It is estimated that about 140 million girls and women worldwide are living with the consequences of mutilation, but condemnation of the practice by groups such as the World Health Organisation and the United Nations Children's Fund appear to be making a difference. The WHO says there is growing political support to end the practice and laws against it have been introduced in 22 African countries, as well as 12 other countries with migrant populations from countries where it is practised.
There is little firm evidence that female genital mutilation is being performed in Australia, despite recent charges over the alleged mutilation of sisters aged six and seven in Sydney between 2010 and this year. A sheikh and retired nurse from an Islamic sect in Sydney's west have been charged, along with the girls' parents, and the case is due to return to court next year.
In a survey of 530 obstetricians, gynaecologists and community workers last year, seven said they had heard anecdotal reports of female genital mutilation taking place in Australia or New Zealand. Two said they had been asked to perform circumcisions and had declined. Seven said they had heard anecdotal reports of girls being taken overseas for genital mutilation.
Study co-author Sonia Grover, who is director of gynaecology at the Royal Children's Hospital, said her research had failed to uncover any direct evidence of mutilation being performed in Australia. In addition, she said, there were no reports of any girls presenting to hospitals with complications from recent female genital mutilation.
However, what is occurring in Australia is a dramatic rise in the number of women undergoing labiaplasty or vulvoplasty. Medicare figures show that women undergoing the surgeries, which reduce the size of their genitals, have more than doubled in Australia over the past decade from 640 women in 2001 to 1558 last year. The biggest increase has been among young women aged 15 to 24 years - from 99 women in 2001 to 359 last year. A total of 383 women aged 25 to 34 had the surgeries last year, accounting for the highest number by age group and up from 186 in 2001.
Royal Australian and New Zealand College of Obstetricians and Gynaecologists vice-president Ajay Rane says such surgery is "the modern version of FGM [female genital mutilation]".
He said labioplasties and vulvoplasties could be performed for legitimate medical reasons, including for excessively protruding labia minora that cause discomfort during exercise and sex. But doctors believe many are being done for cosmetic reasons, and women need better information about the range of sizes and shapes of female genitalia.
"We advise extreme caution to women seeking genital cosmetic surgery," Rane said. "We believe it is culturally driven, and it's a culture of pornography and sexual liberation. It is cutting part of your genitals, the same as with FGM. We've got to tell women that there is no magical panacea. The so-called Barbie doll . . . appearance is not the norm for all genitals for all women of all ages."
* Not her real name.