Female Genital Mutilation (FGM) involves partial or total removal of female genitalia or other injury to female genital organs. In Somalia, FGM is primarily performed on girls aged 4-11. The document highlights issues pertinent to FGM eradication in Somalia.

For futher information, contact: Silvia Danailov, Child Protection Officer, UNICEF Somalia, email: [email protected].

For more information about UNICEF and how it is working in Somalia to improve the lives of children and youth, women and families please contact: UNICEF Somalia Communication Section P. O. Box 44145, Nairobi, Kenya, Telephone 254-20 623958 / 521396, Facsimile 254-20 520640

Eradication of female genital mutilation - An advocacy paper

The day I wore my new dress. by Maggie Black

Fatima is a young mother, whose first baby was premature and stillborn, but her second a healthy boy came to term and survived. She is against circumcision, because the experience for her was horrendous.

Her mother was a seamstress, and usually went off to work in the morning. One evening, when Fatima was aged six, she gave her a new dress, and told her to wear it the following day. 'I was very happy with my dress I had no idea what was going to happen. Then my mother told me she would stay home that day and not go to work, and I was more happy. Then she said I need not go to Qu'ranic school today, and I was even happier.

'I remember that a fat woman came. She started talking to my mother, and my mother was cooking, laughing, and drinking tea. Everyone was happy, and my mother gave me some nice food. Then after a time, she told me to go to the bathroom and have a shower. She said she did not want the woman to see me dirty, so I should wear my new dress.

'My grandmother arrived. She told me I was to be circumcised but I did not understand. She said: "Now you will be like everybody else, you will not be left behind." Then they got ready. They held me at my shoulders and at the knees, and I started crying and trying to close my legs. It was very terrible. I can never forget that.' Fatima falters as she recalls the trauma. She picks up the story only after the worst was over. 'I was at home for seven days with acute pain in the area they had cut. I was not allowed to drink water, and I couldn't eat any solid food.'

Fatima and her friends do discuss circumcision. 'People know it is dangerous and brings difficult births, they hear this on the radio. There are those who say we should stop. If it was up to me, I would say: "Don't do this to your daughters," but I'm afraid society would not accept. My mother knows there are problems, but she believes it is a rule. She thinks it is shameful to live with the genital area open. She will always insist that we have to close it.' Fatima's name has been changed to respect her privacy.

ISSUE

Female Genital Mutilation (FGM) is defined as procedures involving partial or total removal of female genitalia or other injury to female genital organs. In Somalia, FGM prevalence is about 95 percent and is primarily performed on girls aged 4-11. FGM can have severely adverse effects on the physical, mental and psychosocial well being of those who undergo the practice. The health consequences of FGM are both immediate and life-long. Despite the many internationally recognized laws against FGM, lack of validation in Islam and global advocacy to eradicate the practice, it remains embedded in Somali culture.

Female genital mutilation is a social ritual performed in 28 countries ranging from Africa to the Middle East and some of the Islamic Asian countries. It is estimated that the most severe form of the practice affects 130 million women, most of whom were circumcised before puberty. The practice itself often takes place in remote rural areas by untrained village midwives who use instruments such as knives, razors or even broken glass. The instruments are often not sterile and the ritual is very often performed in unsanitary conditions. In urban areas, some families use a doctor to perform the operation.

The operation involves the total removal of the clitoris, labia minora and severing of the inner side of the labia majora. The sides of the labia majora are then sutured together, leaving a small hole to allow urine and menstrual discharge to pass. The practice often occurs without the use of anesthesia.

EFFECTS OF FGM

Beyond the obvious initial pain of the procedure, the long-term physiological, sexual and psychological effects of FGM/C are well documented. The consequences can even include death as a result of shock, hemorrhage or septicemia.

Long-term complications include loss of libido, genital malformation, delayed menarche, chronic pelvic complications and recurrent urinary retention and infection. FGM victims are also prone to a number of obstetric complications because the fetus is exposed to a range of infectious diseases and faces the risk of having its head crushed in the damaged birth canal. Infibulated women, whose genitals have been tightly closed, have to be cut open to allow the baby to emerge.

Perineal tears, obstructed labour and fistula can occur. The repeated cutting and re-stitching of a woman's genitals with each birth can result in tough scar tissue. In addition to direct adverse health effects, FGM increases the woman's biological vulnerability to HIV transmission if exposed to the virus.

The case studies collected by UNICEF as part of a larger survey on Knowledge, Attitudes, Beliefs and Practices around FGM consistently revealed complications and negative consequences of FGM, which can be broadly divided into four thematic areas:

1. The medical effects of the practice;
2. The psychological effects of the practice;
3. The dangerous traditional practices that accompany FGM; and
4. The cultural stigma associated with girls who are not circumcised.
1. Medical complications
2. Psychological effects
3. Traditional practices

The case studies revealed an entire gamut of medical complications, including: tetanus infection leading to death; severe bleeding during the procedure and later during deinfibulation; complications during childbirth; inability to urinate; septicemia, sometimes leading to death; severe muscle contractions; and difficulties in breathing.

FGM can also increase the likelihood of a girl contracting HIV if unsterilized equipment is used. In one of the case studies, the circumciser performed FGM on five young girls consecutively, with one of them being HIV positive. The main link between FGM, HIV/AIDS and heightened vulnerability for transmission, however, comes from the increased incidence of reproductive tract and lower pelvic infections that provide a 'doorway' for HIV to enter the body when in contact with the virus.

The psychological effects of FGM on both women and men are significant. When undergoing the procedures, girls are often told something good is about to happen (see box) and are told that they are becoming pure by the removal of 'unclean' or impure body parts. The pain and trauma of the procedure, which almost none are prepared for, can have lifelong effects.

As well, the deinfibulation process can have serious and long-term psychological consequences. In one of the case studies, the woman involved is so traumatized in the process of deinfibulation on her wedding night, that she burns herself to death. In another of the case studies, a husband is taunted by his family for being unable to have sex with his circumcised wife. He responds by forcing violent intercourse and her obvious pain and screaming traumatize him to the extent that they cease to have a sexual relationship. They are soon divorced, and his mental health deteriorates steadily. In yet another case, the husband is unable to deinfibulate his wife and eventually commits suicide.

There are many dangerous traditional practices associated with FGM, which are highlighted in a number of the case studies. In one case study, the family of a seven year old girl in Kismayo place her above open fire in order to apply smoke to her genitalia to allow urine to pass. Her genitalia becomes badly burned and she dies as a result.

In many parts of Somalia, it is a disgrace for a man to be unable to deinfibulate his wife with his penis alone. This can cause them to use other, dangerous means of deinfibulation. In one of the case studies, the husband applies a corrosive chemical to his wife's vagina, causing her to lose consciousness. Similarly, another husband uses a razor, causing major damage. In advocating against FGM, it is also equally important that these dangerous practices are also eliminated.

4. Cultural stigma associated with those who are not circumcised

In the struggle to eliminate the practice of FGM, it is vitally important to address the cultural discrimination toward women who are not circumcised. In the context of Somalia , with an FGM prevalence of 95-98 percent, this struggle is particularly important. If this change in attitude does not take place women may feel that the pain endured by their daughters during and after circumcision is a lesser evil than the emotional and economic hardship they will endure by remaining unmarried.

As a theme, cultural stigma towards women who remain uncircumcised is touched upon in the case studies. In a case study entitled 'a bridegroom from Canada', the bridegroom, returning from the Disapora to find a wife, becomes upset when he learns from his prospective father-in-law that his bride is uncircumcised. He refuses to marry her and returns to Canada.

In Somali society, the practice of FGM is an honoured tradition. Those who oppose it do so against the tide of public opinion. However, these groups and individuals are slowly making an impact and, with support, can slowly alter the perception and eventually the practice of FGM in the country.

The following case studies illustrate some of the negative results of FGM as well as some of the ways in which the various national and international groups are working, slowly but purposefully, toward the eradication of FGM in Somalia.

Hersi, 55, has lived in a refugee camp for the past 10 years. For many years she used to circumcise young girls but stopped when she reflected on the suffering she herself had undergone. However, despite the best efforts of field staff and NGOs, she alluded to the deep-rooted traditional beliefs and lack of awareness and knowledge, particularly among those from older generations: "There are still traditionalists in the camp. When they want me to make a deep cut and I refuse, they get angry".

In many parts of Somalia, a chronic state of ignorance is compounded by a dangerous set of traditional practices. The following story is a powerful reminder of the need for continued awareness raising and advocacy, particularly in the rural remote areas: "A seven year old girl from Kismayo had been circumcised. For three days she suffered from being unable to urinate and showed signs of infection. The parents dug a hole in the yard and put fire in it with the stools of a camel. They believed this would control the infection. The girl was seriously burnt, and died six months later."

Fatuma Hassan, who works with Somali refugees on behalf of the National Committee on Traditional Practices in Ethiopia, spoke about the need for continued action: "Education is the best way to halt mutilation, but posters and workshops are not enough.the circumcisers may be aware of the harmful effects of FGM, but if they do not have something else to do, then they will continue to practice it."

Women who practice FGM earn vast sums by Somali standards, whether at home or in refugee camps.

Somali culture is very flexible, and if viable alternative incomes can be found for their circumcisers, one day they may be willing to stop the practice altogether.

It is often the case that men, despite knowing the risks and complications associated with FGM, continue to insist on marrying circumcised women. This story was told to UNCEF as another example of how increased awareness and knowledge does not necessarily led to changes in behaviour.

"A man came from Canada to take a wife from Hargeisa, and his family chose a nice girl from a good family. The arrangements for the wedding went smoothly. The man was happy. Just before the wedding, the father decided to inform the man that his daughter was not circumcised. Once the man came to know that his chosen bride was not circumcised, he left the place quietly and without greeting anyone. He went back to Canada the next day. Luckily, the girl married a year later..."

IMPACT - SELECTED CASE STUDIES

Case 1 - Low awareness/traditional, intransigent attitudes
Case 2 - Low awareness/knowledge
Case 3 - Increased awareness/knowledge, but negligible behaviour change due to various factors
Case 4 -Behaviour change
Case 5 - Behaviour change

An aid worker described a visit to a village near Hargeisa to see two sick girls: "We were called to the village to visit two girls who had become sick after an FGM operation. After inquiring as to who had performed the operation, we discovered that it was an elderly lady, who provided her 'service' to villages within a 50km radius. She showed us the place where she performed the operation, which was near to where she kept her animals, and patently unhygienic. Discussions with the old lady revealed that she was aware of the debates surrounding FGM, having attended community level discussions on the topic.

However, she believed it to be part of the Koran and Somali tradition, and she pointed out that she had no alternative source of income. We encouraged her to attend more meetings on the topic, particularly with religious leaders, and also offered to provide her with training on how to be a Traditional Birth Attendant. Six months later, she started work as a Traditional Birth Attendant in Gabiley, a small town in Northwest 'Somaliland'.

Medina Hassan, 55 years old, had been mutilating girls all her life. In early 1996, Medina says, she threw her time-worn blades away. They were knives that had cut more than 3000 girls, perhaps as many as 15000, she had lost count. Sometimes as many as 10 mothers would come each week seeking her 'services' for their daughters, who normally ranged in age from six to 11. In 1993, she took part in a training and information campaign in the camp that focused on FGM. The campaign targeted circumcisers, traditional birth attendants, religious and community leaders. The programme explained to women participants that the urinary, kidney and menstruation discomfort and complications most of them had experienced throughout their lives are a direct result of the rite of passage they suffered as a child. She subsequently stopped being a circumciser.

`I was given basic training...' by Maggie Black

Asha Moalim Ahmed, now in her fifties, has been practising as a TBA for 31 years, having learnt the skills from her mother. In 1975, she received a formal training as a TBA. At the time, like others, she was also taught how to do circumcisions with clean instruments, using anaesthetics. There was little effort then by health professionals to discourage the practice.

Asha lives south of Mogadishu, in Bulo Mareer. A year ago she went to a seminar where she was told that pharaonic circumcision was bad, and since that time, she says, people have been less keen. 'Pharaonic is going down, and people now ask for sunna.' This involves less cutting and does not include excision of the clitoris, but although it is far less severe, it still involves some mutilation. 'I myself do not like pharaonic. My father told me long ago that it is against religion and I should only perform sunna. I discourage parents. But some insist, because they think pharaonic is more beautiful.'

Bulo Mareer is typical of towns in the south in that it is divided, with one part under one clan authority and the other run separately. Asha knows all the TBAs in her own part, and says they are all dropping pharaonic. 'On the other side where the MCH clinic is, I met seven girls being circumcised by pharaonic. All the MCH staff were circumcising, and some were insisting on pharaonic.

They are educated and have influence. They should know better.'

CONSTRAINTS

UNICEF ACTION

The case studies above were chosen to illustrate the three stages that people are at in Somalia: (1) complete lack of awareness, (2) minimal awareness but negligible behaviour change, and (2) awareness and behaviour change. Yet the stories also reflect some of the constraints faced by those seeking to end FGM. In the first anecdote, Hersi, came under tremendous pressure from traditionalists in the camp to perform FGM on their daughters and/or female relatives. Deep rooted traditional beliefs and a lack of awareness still exists, notwithstanding the efforts of the international and national community. The second case study, where smoke is applied to the genitalia of a seven year old, is a stark reminder of the ignorance, traditional customs and overall lack of awareness and knowledge that often prevails in rural areas.

The third case, Fatuma Hassan argues that not only is it important to educate the community about FGM, but that alternative sources of employment need to be found for the circumcisers, who will otherwise continue to promote the practice. She says, "Education is the best way to halt mutilation, but posters and workshops are not enough.the circumcisers may be aware of the harmful effects of FGM, but if they do not have something else to do, then they will continue to practice it."

Case four illustrates that an increased exposure to potential knowledge and awareness does not necessarily translate into a change in behaviour. The Somali man from Canada still insists that his wife be circumcised, in spite of, or perhaps because of, being part of the Somali Diaspora.

Thankfully, in Case Study five, the UN worker manages to persuade the FGM practitioner to give up the practice, and arranges for her to undertake training to become a Traditional Birth Attendant.

Case Study six offers another good example of positive behaviour change. In the story, a practictioner o gives up FGM after attending a series of workshops targeting circumcisers, traditional birth attendants, religious and community leaders. The workshops highlighted the many negative consequences of the practice.

Another potential constraint can be the attitudes and advocacy strategies adopted by the international community. Rather than judging communities and condemning Somali society, a sensitive long-term approach is needed that takes into account the local context. In this respect, the voices of the Somalis themselves are vital.

While UNICEF is firmly committed to respecting the cultural identity and traditions of the countries in which it works, it is clear about the unacceptability of traditional practices that violate human rights, and specifically the rights of children. Action on eliminating harmful traditional practices is specifically mandated by the Convention of the Rights of the Child, and FGM is clearly such a practice.

In its work UNICEF will develop, fund and implement interventions for the reduction of physical and psychological violence against children, whether in the family, the community, in schools and other institutions or in the form of harmful traditional practices'. Violence and abuse include physical, sexual and psychological violence against children within the families, in schools and communities and in the State and non-State institutions: gender related violence and female genital mutilation'.

As FGM in Somalia is performed on young girls, it is not easy to take lessons learned from documented successful interventions such as the replacement rituals in Uganda where FGM is largely performed as part of the initiation rite to womanhood. The young age of the girls, compounded with low levels of school enrolment, make it difficult to target interventions to the girls themselves. Interventions aiming at immediate reduction in FGM therefore primarily target young adults, whose girls are approaching the age when FGM is performed, as well as opinion leaders that can influence the decisions of individual families.

The long-term shift in cultural norms requires awareness-raising through education and community mobilization in order to bring up a generation that does not feel bound by the need to gain acceptance through conforming to the practice, as well as creation of a new generation of leaders that work against the continuation of the practice.

To achieve consensus about eradication of FGM, a sensitive, long-term approach is required, one that is participatory and ensures community ownership of the initiative. Creative interventions are the key to addressing this complex issue. UNICEF programme activities have included workshops bringing together authorities, elders, religious leaders, health workers, women, youth, educators, displaced, and refugees to debate and reach consensus, within the context of Islam, about total eradication of the practice.

Currently, the focus of UNICEF interventions is on advocacy and mobilization of communities. As the prevalence of the practice in Somalia is almost universal, and there is stigma and discrimination attached to abandoning the practice, UNICEF is committed to the creation of an enabling environment where individuals are empowered to make decisions based on the best interest of their children. This strategy is based on the belief that the practice will not end only by targeting the circumcisers, but rather by engaging with the families with young girls, focusing on youth who will be future parents, and targeting the leaders who have influence over community members. In other words, by reducing the demand for the practice, it will eventually become obsolete.

The UNICEF interventions fall into two categories:

Interventions aimed at behaviour change through awareness-raising and increased capacity of individuals and communities to make choices that break the current 'norm' (short-term impact). Interventions aimed at change in the societal norms i.e. change in the status of FGM as a desirable act within the society at large (long-term impact).

Many target groups have been identified in the FGM elimination effort, including men, women, male youth, young girls, and older women. It is important to reduce both the supply and demand for FGM. This entails finding an alternative occupation for the practitioners of FGM, such as being a traditional birth attendant or teacher, and also cultivating a situation whereby young men no longer wish to marry circumcised women.

In these efforts, groups and individuals must anticipate a long struggle, as old customs and beliefs take time to change. Women who feel that circumcising their daughters will ensure virginity before marriage and faithfulness during it may still choose to apply some form of FGM. Nevertheless, the case studies offer examples of the changing views regarding the practice held by Somalis themselves. Furthermore, there are numerous examples of 'positive behaviour change' that have taken place, such as the male members of a youth group in Hargeisa, Somaliland, who have pledged to marry only uncircumcised women.

Such examples are on the increase especially in urban settings were information is readily available and public debate takes place. These are a testimony to the fact that individual and collective victories are being won every day in the struggle to eradicate FGM. If the efforts of the international and national community can continue and increase, the future for the young and unborn Somali girl will be incrementally better with each passing day.

CONCLUSION

1. A DISARMAMENT CELEBRATION IN BERBERA

Ha!', Ha!'. At the Regional Education Centre in Berbera, Somaliland's major port, a large gathering is in process. At the podium is the Mayor, flanked by colleagues from City Hall, doctors, officers from the MCH health services, sheikhs, and visitors from other regions. Notices on the wall about today's event are written in military language. The time has come to 'disarm', to 'put down the weapons used against girls'. In his speech, the Mayor announces: 'I want to make it clear that, in the Regional Authority, we are with the war against FGM'. To have such men speak out in such terms is a breakthrough.

Sado, head of MCH, is the first of many speakers to welcome the six most well-known circumcisers of Berbera who are about to disarm voluntarily, witnessed by a crowd of health professionals and well-wishers. Many speakers follow her example in highlighting the difficulties 'we have all experienced' and the changes that are underway. Hodan from Gebile learnt while she was abroad that Somalis are exceptional. 'In the nine years I was in Saudi Arabia, I never met a woman who knew about FGM. When a Somali woman was to give birth in a Saudi hospital, they had to send for a doctor from Mogadishu - they did not know what to do. So I saw that it had nothing to do with Islam.'

Finally, the moment of renunciation comes. Sado turns to the six waiting circumcisers. 'Do you agree to give up this practice?''', they all cry,''. The first to come forward is Asha, the oldest. She lays down her gloves, her needle for suturing, sugar to dry the labia, local anaesthetic, a syringe, cotton wool, and a clean razor blade. She makes her statement to loud applause: 'I am praying Allah to forgive me for what I have done before, and I swear that I am not going to do it in the future.'

When all six have disarmed, it is time for singing and dancing. A young girl who could never dance so freely if she had been cut and sewn together between her legs, leads the dancing: she is the promise of the future. The songs are the ones the FGM teams have written. 'FGM is against nature, FGM is against what Allah brought us. What Allah creates is best, No-one can change it for the better. Take care of your daughter. Take care of your son-in-law who is suffering as your daughter is suffering. Don't cut your daughter.' -By Maggie Black

Ha! Ha!