Genital mutilation of girls in Sudan : Community- and hospital-based studies on female genital cutting and its sequelae

Sammanfattning: Background: In spite of many decades of campaigns, female genital mutilation (FGM) is still highly prevalent in Sudan. One reason for this might be that campaigns have failed to approach fundamental values of FGM. In the absence of previous paediatric research on FGM, immediate and long-term complications for girls are basically unknown, as is their clinical picture. Methods: Interviews were carried out according to questionnaires with open answers with 119 randomly selected respondents (30 young mothers, 29 young fathers, 30 grandmothers and 30 grandfathers) in a village in the Gezira in Sudan. To investigate adverse health effects on the child, 255 consecutive girls aged 4-9 years presenting to the Children's Emergency Hospital, Khartoum, were recruited. A detailed history was obtained and full examination, including inspection of genitalia, and investigations were performed to diagnose urinary tract infection (UTI). To investigate the association between FGM and primary infertility we performed a casereferent study. Cases were 99 women with primary infertility, among whom hormonal and iatrogenic causes, as well as male factor infertility were excluded. Cases underwent diagnostic laparoscopy. Referents were 180 primigravidae women recruited from antenatal care. Results: While all female respondents in the village had undergone FGM, 44% of the young respondents had decided not to let their daughters undergo it. This change of practice was confirmed by the clinical study where 22% of the girls had undergone FGM, but a large share of the rest would have FGM later, leaving 26% of the girls allegedly without FGM in the future. The form of FGM was under-reported in an anatomical sense, 39% of forms being reported as "Sunna", extending to the labia majora. For girls under the age of 7 there was a significant association between FGM and suspected UTI. Symptoms from the urogenital tract in girls were heavily under-reported. Tradition and social pressure were the main motives for performing FGM. Religious belief, education level and socio-economic status significantly affected to what extent FGM was practised. Sexuality was an important aspect, mentioned as a motive both for and against FGM. Reinfibulation was widely practised in this area, with the main motive being sexual satisfaction of the husband. This was contradicted by the fact that male complications resulting from FGM, such as difficulty in penetration, wounds/infections on the penis and psychological problems were described by a majority of the men. Most of the young men would have preferred to marry a woman without FGM. Consequently, young fathers were more involved in the decision process when decisions were taken not to perform FGM. After controlling for age, education, socio-economy, and sexually transmitted infections, cases with primary infertility had a significantly higher risk than referents of having undergone the most extensive form of FGM involving labia majora (OR 4.69; 95% CI 1.49, 19.7). The anatomical extent of FGM, rather than whether or not the vulva had been sutured/closed, was associated with primary infertility. Interpretation: There seems to be a trend towards abandonment and/or milder forms of FGM in Sudan, but a majority of girls still undergo severe forms of the practice. The validity of reported form of FGM is low. Genital mutilation contributes significantly to morbidity already in childhood, but a large share of this does not come to medical attention. By exposing male complications of FGM, showing male negative attitudes towards the practice, male and female sexual problems related to FGM and that FGM is a likely cause of infertility, the results challenge the most important marriage-related traditional motives for FGM. Traditionally FGM was performed to increase the chances of future marriage. Our findings, on the contrary, indicate that genital mutilation of girls might have an opposite effect by destabilising marriages through its effect on sexual and reproductive health.