The Gambia being largely a cultured society has some deeply entrenched traditional and cultural practices that have been observed and preserved for generations. While so many of these practices are widely held as integral elements of the fabrics of our society, and thus celebrated, some have long been subject of controversy. One prominent controversial practice is Female Genital Mutilation or Cutting (FGM/C).
Being a very wide and complicated discourse, FGM/C has many different forms and sub-practices including infibulation (sealing). This article is about sealing and its implications on victims and society at large. However, for a better understanding of the practice and of sealing it must be viewed within the wider context of FGM/C.
According to the World Health Organistion (WHO) Female Genital Mutilation or Cutting comprises all procedures that involve partial or total removal of the external female genitalia, causing injury to the female genital organs for non-medical reasons.
Additionally, FGM/C involves procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons (WHO, 2020).
The WHO also classified Female Genital Mutilation or Cutting is classified into 4 major types: Type 1: Often referred to as clitoridectomy. This is the partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals), and in very rare cases, only the prepuce (the fold of skin surrounding the clitoris) is a leftover.
Type 2: Often referred to as excision, this is the partial or total removal of the clitoris and the labia minora (the inner folds of the vulva), with or without excision of the labia majora (the outer folds of skin of the vulva).
Type 3: Often referred to as infibulation, this is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoris (clitoridectomy). Type 4: This includes all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area (WHO, 2020).
Immediate complications can include: Severe pain, excessive bleeding (hemorrhage), genital tissue swelling, fever, infections e.g., tetanus, urinary problems, wound healing problems, injury to surrounding genital tissue, shock and death.
Urinary problems (painful urination, urinary tract infections); vaginal problems (discharge, itching, bacterial vaginosis and other infections); menstrual problems (painful menstruations, difficulty in passing menstrual blood, etc.); scar tissue and keloid; sexual problems (pain during intercourse, decreased satisfaction, etc.); increased risk of childbirth complications (difficult delivery, excessive bleeding, caesarean section, need to resuscitate the baby, etc.) and newborn deaths.
The practice is mostly carried out by traditional circumcisers, who often play other central roles in communities; such as attending childbirths. In many settings, health care providers perform FGM due to the erroneous belief that the procedure is safer when medicalised. World Health Organisation strongly urges health professionals not to perform such procedures.
The WHO 2018 report on FGM/C show that procedures are mostly carried out on young girls sometimes between infancy and adolescence, and occasionally on adult women.
More than 3 million girls are estimated to be at risk for FGM annually. More than 200 million girls and women alive today have been cut in 30 countries in Africa, the Middle East and Asia, where FGM is concentrated. The practice is most common in the western, eastern, and north-eastern regions of Africa (WHO, 2020).
According to the United States Department of State report on FGM/C in the Gambia, the estimated percentage of all women in The Gambia who have undergone one of the forms of FGM/FGC ranges from 60 to 90 percent.
The Foundation for Research on Women's Health, Productivity and the Environment (BAFFROW) reports that seven of The Gambia's nine ethnic groups practice one of these forms. Nearly all Mandinkas, Jolas and Hausas (together 52 percent of the population) practice Type II on girls between 10 years and 15 years of age. The Sarahulis (nine percent of the population) practice Type I on girls one week after birth. The Bambaras (one percent of population) practice Type III, which takes place when girls are between 10 years and 15 years of age. The Fulas (18 percent of the population) engages in a practice analogous to Type III that is described as "vaginal sealing" or Type IV on girls anywhere between one week and 18 years of age.
The Wolofs, Akus, Sereres and Manjangos (together 16 percent of the population) generally do not practice any of these forms. However, if a woman marries a member of an ethnic group that engages in this practice, she may be forced to undergo the procedure prior to marriage. Of those who have undergone any of these procedures, twenty percent are below the age of five and fifty percent are between the ages of five and eighteen, with the average being approximately age twelve. The urbanized areas of the western division have a high concentration of ethnic Wolofs who do not practice any of these procedures.
The Report quoted a Gambian doctor who practiced medicine in The Gambia for over 20 years and later became the regional director of the World Health Organization, as saying they documented that between 300 and 400 women died during childbirth every year from complications attributable to Type III or Type IV.
A 2015 Guardian Media report says 76% of females have been subjected to FGM/C. The Report indicated that the age at which FGM takes place in the Gambia is not recorded, but that it is reported that the trend of practicing FGM on infant girls was on the rise. By the age of 14, 56% of female children in the country have had the procedure (The Guardian, 2015).
Fatou Kinteh is the Gambian minister of Children and Women’s Affairs. She reported that around the year 2000, FGM/C and sealing prevalence across the country was about 95% but that the rate dropped to 76% by 2013 and now about 52%. She ascribed this moderate success to the interventions of development partners like UNFPA, and UNICEF, as well as vigorous advocacy, awareness creation efforts by various stakeholders.
She affirmed that sealing remained an inherent practice, premised on the misconception that when a girl is sealed, she is prevented from indulging in promiscuity and so keep her chastity.
However, FGM/C and all its forms, has been banned in The Gambia since 2015. Madam Kinteh warned that anyone who is found practicing the act will be charged for criminal offence and will face the consequences of the law. “Section 32A and B of the Women Amendment Act 2015 clearly stated the repercussions for practicing and supporting the act of FGM/C and sealing will be dealt with,’’ she warned.
Madam Sira Bah is a Gambian retired Community Health Nurse and Midwife, who also spoke to me about the danger of sealing. She said the procedure can cause severe bleeding and problems of urinating and later cysts, infections, as well as complications in childbirth and increased risk of newborn deaths. FGM in general, she opined, is a violation of the human rights of girls and women.“FGM has no health benefits, and it harms girls and women in many ways. It involves removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls' and women's bodies,” she added.
The reasons why female genital mutilations are performed vary from one region to another as well as over time, and it includes a mix of sociocultural factors within families and communities. The most commonly cited reasons are: Where FGM is a social convention (social norm), the social pressure to conform to what others do and have been doing, as well as the need to be accepted socially and the fear of being rejected by the community, are strong motivations to perpetuate the practice. In some communities, FGM is almost universally performed and unquestioned.
It is often considered a necessary part of raising a girl, and a way to prepare her for adulthood and marriage. And where it is believed that being cut increases marriageability, FGM/C is more likely to be carried out.
For Madam Sira Bah FGM/C is also associated with cultural ideals of femininity and modesty, which include the notion that girls are clean and beautiful after removal of body parts that are considered unclean, unfeminine or male.
Although no religious scripts prescribe the practice, practitioners often believe the practice has religious support.
However, religious leaders take varying positions with regard to FGM/C: some promote it, some consider it irrelevant to religion, and others contribute to its elimination.
Nonetheless, local structures of power and authority, such as community leaders, religious leaders, circumcisers, and even some medical personnel can contribute to upholding the practice.
However, in most societies, where FGM/C is practiced, it is considered a cultural tradition, which is often used as an argument for its continuation.
In some societies, recent adoption of the practice is linked to copying the traditions of neighboring groups. Sometimes it has started as part of a wider religious or traditional revival movement. (WHO, 2018).
For Oustass Karim Gibba of Bundungka Kunda, an Islamic scholar, FGM/C though was long being practised in the Muslim world; as far back as in the days of the Prophet Muhammed, peace be upon him, the practice is not compulsory in Islam. “The Prophet Muhammed (P.B.U.H) did advise that if in any case people cannot stop the practice they must cut only a small part; not everything”. The latter the Oustass said, is a violation of the woman’s right to enjoy sex. ‘‘People should not or misinterpret or conflict religion with culture and tradition,” he added, advising religious scholars to clearly communicate the teachings of Islam to the people.
Since 1997, great efforts have been made to counteract FGM/C, through research, work within communities, and changes in public policy. Progress at international, national and sub-national levels includes: wider international involvement to stop FGM; international monitoring bodies and resolutions that condemn the practice; revised legal frameworks and growing political support to end FGM (this includes a law against FGM in 26 countries in Africa and the Middle East, as well as in 33 other countries with migrant populations from FGM practicing countries.
Furthermore, in 2007, UNFPA and UNICEF initiated the Joint Programme on Female Genital Mutilation/Cutting to accelerate the abandonment of the practice.
In 2008, WHO together with 9 other United Nations partners, issued a statement on the elimination of FGM to support increased advocacy for its abandonment, called: “Eliminating female genital mutilation: an interagency statement”. This statement provided evidence collected over the previous decade about the practice of FGM.
In 2010, WHO published a "Global strategy to stop health care providers from performing female genital mutilation" in collaboration with other key UN agencies and international organizations. In December 2012, the UN General Assembly adopted a resolution on the elimination of female genital mutilation.
Building on a previous report from 2013, in 2016 UNICEF launched an updated report documenting the prevalence of FGM in 30 countries, as well as beliefs, attitudes, trends, and programmatic and policy responses to the practice globally.
In May 2016, WHO in collaboration with the UNFPA-UNICEF joint programme on FGM launched the first evidence-based guidelines on the management of health complications from FGM. The guidelines were developed based on a systematic review of the best available evidence on health interventions for women living with FGM.
Madam Sira Bah also intimated that in order to ensure the effective implementation of the guidelines, WHO is developing tools for front-line health-care workers to improve knowledge, attitudes, and skills of health care providers in preventing and managing the complications of FGM/C. However, studies have shown that the prevalence of FGM/C has decreased in most countries and an increasing number of women and men in practicing communities support ending its practice.
Research also shows that if practicing communities themselves decide to abandon FGM/C, the practice can be eliminated very rapidly.
Virginal “sealing" also known as infibulation involves the removal of the clitoris and the labia minora, followed by sealing the vaginal opening with clots of blood or herbal powder leaving only a small opening, about the diameter of a matchstick, for urination and menstruation. The legs are forced to stay tightly together during the period of convalescence (about 40 days) allowing the raw vaginal tissue to fuse.
A woman of the blacksmith's class who is believed to be gifted with knowledge of the occult traditionally carries out these procedures. Various instruments are used. Fingernails have been used to pluck out the clitoris of babies in some areas of the country. The procedure is often performed by a village excisor without the use of anesthesia. Instead, several women hold the girl or woman down while the cutting takes place (United States Department of State, 2001).
In addition, the process entails leaving the blood clots of the victim of FGM/C to dry in the walls of the virgina which later become concrete, thus making penetration during intercourse difficult or even impossible.
Sutering Drammeh is also a midwife for thirty-eight years, posted in the Central River Region. He said ‘‘sealing deprives the victim women and girls from the normal opening of the virginal organ called critical manorial from the easy flow of the blood”.
“Largely, girls are sealed to avoid sexual penetration, in order to preserve their virginity until marriage. In the context of socio-cultural perception in societies that practice it, there is virtue in virginity. A woman’s chastity is regarded as her biggest asset, and a treasure for her family that must be protected at any cost. In Gambia too, it is still a big deal albeit not as sacred now as it was some years ago. When girls get married and are found to be virgin, they are celebrated and the family feel highly esteemed,” Madiba Sillah, Principal Information Officer at Department of Information Service and social commentator.
Madam Sireh Bah affirmed that infibulation is done to discourage extramarital sexual intercourse among women, by making it difficult and impossible for men to penetrate them should they attempt an intercourse.
Medical professionals have reported complications attached to this highly revered yet dangerous practice. Sutering Drammeh reported that they have experienced dealing with several cases of young girls who could not pass urine due to the pressure from the virginal orifice. “This can lead the victims to having ascending infection from the virgina to the uterus depending on what type of pathogen and can also make the victim to be sterile”.
He went on: “It is so disheartening when you find out most of the victims’ husbands cannot penetrate them because they are sealed during virginal examination”. He said there is difficulty during menstrual flow of the blood because the passage is blocked and it remains in the uterus.
Dr Momodou T. Nyassi, Senior Medical Officer at the Obstetrics and Gynaecology department of the Bansang Hospital explained that the menace of the female genital mutilation or cutting and sealing has social, psychological, and sexual problem implications on girls and women in The Gambia.
Sealing, he added, involves the total removal of the female genital area with which it is later sealed to prevent a woman or a girl child from convenient sexual intercourse. “In most cases, these practices are conducted without any injection leading to instances of neurological shock, excessive bleeding (anaemia), infections, injury to the adjacent tissues, fracture and even death”.
Other probable medical complications, Dr Nyassi said include hepatitis infections, HIV AIDS, pelvic infection, and urinary retention “due to the fact that the splinter of the urine has been cut leading to the in-control of the urine”.
“After sealing the fluids and keloid found around the cut can also inflict pain; especially during labour, and can also interfere with their normal biological system,” he added.
Dr Nyassi further explained that FGM/C and sealing can also affect the virginal lubricator that ensures lubrication during sexual intercourse.
The doctor lamented the fact that most of the traditional initiators are bad at it; noting that the way they remove the clitoris and the labia minora (tissue that covers the virgina) can be dangerous.
He warned that sometimes the process by which sealing is done can tamper with many organs; much especially the ureter, which once it is sealed can make it difficult for the menstrual flow of blood. This he added, can make the blood to accumulate in the stomach and is painful. “If accumulated for months and is not corrected on time, it can lead to pelvic infections and infertility".
Further on potential complications Dr Nyassi said FGM/C and sealing can tamper with blood vessels and the bladder, creating a hole between the virgina and the bladder thereby causing urine to leak from the bladder to the virgina. The likely illness from this situation, the Dr added, is fistula. “Sometimes extended cutting and sealing of the clitoris, whereby the clitoris is cut deep down to the virgina can lead to recto virginal fistula, whereby the waste products past through the virgina. This leads to infection or infertility. During delivery this can cause the womb to burst because it is tight, resulting to internal bleeding and both the parent and the child can die.
Mariatou Sanneh, an initiator/circumciser from the Upper River Region of the Gambia, a region that is notorious for FGM URR, has a different view point about FGM and sealing. She opined that this is a well revered ancestral practice that must not be neglected. She argued that they have been practicing FGM for years without any major problems. “It inculcates in the initiated child discipline, respect and restraint; and more especially, it is about adhering to the Sunnah of Prophet Muhammed (P.B.U.H)”.
For Serreh Jabbi, a victim of FGM/C and sealing, the pain inflicted by ‘going under the knife’ cannot be imagined. She attested to the fact that it was extremely hard for her when she got married newly.
De-infibulation refers to the practice of cutting open the sealed vaginal opening in a woman who has been infibulated, which is often necessary for improving health and well-being, as well as to allow intercourse or to facilitate childbirth.
According to Madam Sireh Bah, mostly, circumcisers remove the seals with sharp razor blade, which inflicts pain and cause more blood loss.
She further intimated that sometimes genital tissue is stitched again several times, including after childbirth; hence the woman goes through repeated opening and closing procedures, further increasing both immediate and long-term risks.
The problem associated with this, she said is psychological issues (depression, anxiety, post-traumatic stress disorder, low self-esteem, etc.).
However, according to Dr Nyassi, defibulation is safer done with the right and guided procedure, through the use of injections such as lignocaine. “There needs to be thorough and proper examination to know the space opening, interviewing the patient, applying alcohol, or iodine because they may be keloid, or just a minor opening to ensuring that the victims can be well informed as to how and what they will experience in the removal of the sealing.
FGM/C and sealing although are deep-seated traditional practices, with all kinds of justifications including an attempt to signify it religiously, there is growing consensus that it is a serious violation of the right and freedoms of the victims. The religious justifications for FGM/C and sealing are generally weak and the many medical professionals have guaranteed that it has no medical benefit; just harm.
According to the midwife Sireh Bah there needs to be greater knowledge generation about the causes and consequences of the practices. “There should be increasing advocacy: developing publications and advocacy tools for international, regional and local efforts to end FGM within a generation,” she recommends.
Internationally, FGM is recognised as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. It is nearly always carried out on minors and is a violation of the rights of children. It is argued that the practice also violates a person's rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death notwithstanding.