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The Ebola Epidemic Halted Female Genital Cutting in Sierra Leone: Temporarily: Medical, Anthropological, and Public Health Perspectives
Abstract
This chapter discusses the occurrence of female genital cutting (FGC) in Sierra Leone before, during, and after the West African Ebola virus epidemic. Female genital cutting, also termed female genital mutilation or female circumcision, is a procedure that involves the removal of parts or all of the entire external female genital organs, or other injuries to the external female genital organs, for nonmedical reasons. Sierra Leone has one of the highest rates of FGC in the world, with up to 90% or more of all girls and women having undergone the procedure. In Sierra Leone, it is associated with membership in a secret women’s society, the Bondo Society, which yields enormous social and political power throughout the urban and rural areas of the country. Because it is typically performed under unhygienic circumstances, FGC can result in numerous medical complications including recurrent genitourinary infections, sepsis, pain, hemorrhage, infertility, and even death. FGC is internationally recognized as a violation of the basic human rights of girls and women. During the Ebola epidemic that began in Sierra Leone in 2014, there was a governmental ban on FGC to prevent Ebola virus transmission, not only to the children and girls who were at risk for undergoing the procedure, but also to protect the soweis—older women who are the senior members of the Bondo societies and who perform the circumcision. However, once the Ebola epidemic was over in 2015, there was a return to “business as usual” by the country’s soweis and FGC has returned. In the post-Ebola era, efforts continue to eliminate FGC from Sierra Leone.
Liberia, Africa’s oldest republic founded by freed Black slaves and the American Colonisation Society, was stunted by a civil war that killed 250,000 people and displaced another 850,000 between 1989 and 2003. In 2005, Liberia made headlines for being the first African country to democratically elect a female president. However, the Ebola virus descended upon Liberia on 30 March, 2014. Almost 2 years after, Liberia was the outbreak’s hardest hit country with 10,666 cases and 4806 deaths. The Global Fund for Women suggests 75% of those who died from Ebola were women, with past studies revealing that a mortality rate among pregnant women could be as high as 93.3%. Of the 184 health workers who died, nurses and nursing aids (mostly females) accounted for the highest proportion (35%) of the 810 Ebola health worker cases reported by mid-August 2014. During the Ebola outbreak, both the World Health Organisation and the government of Liberia declared a “public health emergency,” providing an opportunity to canvass various fields of law responsive to the threat of the disease and strengthen public health security. The World Health Organisation declared Liberia Ebola-free for the fourth time on 14 January, 2016. Despite having a crippled health system, an outdated Public Health Act, extremely low numbers of health workers, and under-funded government institutions of health and social welfare, Liberia stands out as a success story in curbing the Ebola outbreak. This chapter examines the extent to which international, regional, and national law and policy impacted upon and contributed to reproductive and maternal health outcomes of girls and women during the Ebola crisis in Liberia.
A year into the Ebola virus epidemic in Sierra Leone, points of friction remained between efforts to contain new outbreaks and community responses to these efforts. As an anthropologist embedded with Oxfam’s Ebola response, my role was to identify and probe these points of conflict, in order to support more inclusive, community-led efforts to prevent new infections and contain outbreaks. Rapid qualitative research revealed that gender and stigma played key roles in prolonging the epidemic. Despite efforts to reduce negative attitudes towards those affected by the Ebola virus, layers of stigma and blame remained embedded in response activities, from government-level policies to community-level interactions. These attitudes strained gender roles in ways that created barriers to compliance with Ebola prevention and treatment advice. This research highlighted the need for deeper community engagement in epidemic response, including reflexive processes on the part of humanitarian responders to interrogate “common sense” assumptions that may reflect Western-centric biases.
One of the consequences of the Ebola crisis was school closures across the subregion. In Sierra Leone, where the authors were based working for the Irish government, a significant increase in teenage pregnancy was reported during the crisis. This was attributed, in part, to the school closures and, in part, to other issues, such as increases in the vulnerability of girls due to Ebola. Much as this picture was bleak, sometimes in a crisis comes unexpected opportunity. Pregnant girls were, de facto, banned from attending school in Sierra Leone prior to Ebola. However, the Ebola outbreak led to an increased awareness of the Sierra Leonean government leadership of the scale of teenage pregnancy in the country. This led to a new partnership of the government of Sierra Leone with the members of the international community, led by Irish Aid, to provide access to the formal education system for pregnant girls. Fourteen thousand, five hundred girls benefited from this programme in its first year, although significant dilemmas and challenges were also encountered. Lessons include the benefit of international actors working closely with government to identify opportunities on issues of concern and to negotiate improved programmes, and then being adaptable enough to support and fund improved programmes if they emerge.
Objective. To determine forms of female genital mutilation (FGM), assess consistency between self-reported and observed FGM status, and assess the accuracy of Demographic and Health Surveys (DHS) FGM questions in Sierra Leone. Methods. This cross-sectional study, conducted between October 2010 and April 2012, enrolled 558 females aged 12-47 from eleven antenatal clinics in northeast Sierra Leone. Data on demography, FGM status, and self-reported anatomical descriptions were collected. Genital inspection confirmed the occurrence and extent of cutting. Results. All participants reported FGM status; 4 refused genital inspection. Using the WHO classification of FGM, 31.7% had type Ib; 64.1% type IIb; and 4.2% type IIc. There was a high level of agreement between reported and observed FGM prevalence (81.2% and 81.4%, resp.). There was no correlation between DHS FGM responses and anatomic extent of cutting, as 2.7% reported pricking; 87.1% flesh removal; and 1.1% that genitalia was sewn closed. Conclusion. Types I and II are the main forms of FGM, with labia majora alterations in almost 5% of cases. Self-reports on FGM status could serve as a proxy measurement for FGM prevalence but not for FGM type. The DHS FGM questions are inaccurate for determining cutting extent.
The practice of female genital mutilation/cutting (FGM/C) has been documented in many countries in Africa and in several countries in Asia and the Middle East, yet producing reliable data concerning its prevalence and the numbers of girls and women affected has proved a major challenge. This study provides estimates of the total number of women aged 15 years and older who have undergone FGM/C in 27 African countries and Yemen. Drawing on national population-based survey data regarding FGM/C prevalence and census data regarding the number of women in each country, we find that almost 87 million girls and women aged 15 and older have been cut in these 28 countries. Producing reliable figures for the number of women affected by FGM/C in these countries allows researchers and program directors to better comprehend the impact of the practice and to mobilize resources for advocacy against it.
Objective:
The study presented in this article explored psychosocial and relational problems of African immigrant women in The Netherlands who underwent female genital mutilation/cutting (FGM/C), the causes they attribute to these problems--in particular, their opinions about the relationship between these problems and their circumcision--and the way they cope with these health complaints.
Design:
This mixed-methods study used standardised questionnaires as well as in-depth interviews among a purposive sample of 66 women who had migrated from Somalia, Sudan, Eritrea, Ethiopia or Sierra Leone to The Netherlands. Data were collected by ethnically similar female interviewers; interviews were coded and analysed by two independent researchers.
Results:
One in six respondents suffered from post-traumatic stress disorder (PTSD), and one-third reported symptoms related to depression or anxiety. The negative feelings caused by FGM/C became more prominent during childbirth or when suffering from physical problems. Migration to the Netherlands led to a shift in how women perceive FGM, making them more aware of the negative consequences of FGM. Many women felt ashamed to be examined by a physician and avoided visiting doctors who did not conceal their astonishment about the FGM.
Conclusion:
FGM/C had a lifelong impact on the majority of the women participating in the study, causing chronic mental and psychosocial problems. Migration made women who underwent FGM/C more aware of their condition. Three types of women could be distinguished according to their coping style: the adaptives, the disempowered and the traumatised. Health care providers should become more aware of their problems and more sensitive in addressing them.
Sierra Leone has one of the highest rates of female genital mutilation (FGM) in the world, and yet little is known about the health consequences of the practice.
To explore whether and what kind of FGM-related health complications girls and women in Sierra Leone experience, and to elucidate their health care-seeking behaviors.
A feasibility study was conducted to test and refine questionnaires and methods used for this study. Thereafter, a cross-section of girls and women (n = 258) attending antenatal care and Well Women Clinics in Bo Town, Bo District, in the southern region and in Makeni Town, Bombali District, in the northern region of Sierra Leone were randomly selected. Participants answered interview-administrated pretested structured questionnaires with open- ended-questions, administrated by trained female personnel.
All respondents had undergone FGM, most between 10 and 14 years of age. Complications were reported by 218 respondents (84.5%), the most common ones being excessive bleeding, delay in or incomplete healing, and tenderness. Fever was significantly more often reported by girls who had undergone FGM before 10 years of age compared with those who had undergone the procedure later. Out of those who reported complications, 187 (85.8%) sought treatment, with 89 of them visiting a traditional healer, 75 a Sowei (traditional circumciser), and 16 a health professional.
The high prevalence rate of FGM and the proportion of medical complications show that FGM is a matter for public health concern in Sierra Leone. Girls who undergo FGM before 10 years of age seem to be more vulnerable to serious complications than those who are older at the time of FGM. It is important that health care personnel are aware of, and look for possible complications from FGM, and encourage girls and women to seek medical care for their problems.
The African grassroots movement to eradicate female genital mutilation (also known as “female genital cutting” and “female circumcision,” hereinafter “FGM”) is widespread. While many African countries and grassroots organizations have made great strides in their efforts to eliminate FGM, Sierra Leone lags behind. In Sierra Leone, FGM is practiced within the bondo secret society, an ancient, all-female commune located in West Africa and also known as the sande. The bondo society’s traditional role was to direct girls’ rites of passage into adulthood. In order to become a member of the bondo, a girl or woman must undergo various rituals, the most significant being FGM. The fact that FGM takes place within secret societies in Sierra Leone makes eradication efforts more challenging. It is for this reason that Sierra Leone has been described as “ground zero” in the fight to eradicate FGM. This article culminates a project undertaken by the Walter Leitner International Human Rights Clinic (hereinafter “Leitner Clinic” or “Clinic”) at Fordham Law School to craft a blueprint for how grassroots organizations in Sierra Leone, and in similarly situated countries, can begin to tackle FGM at the grassroots and policy level in a manner that includes the voices of rural and less powerful citizens. This article argues that FGM eradication efforts, despite the challenging context, can be effective in Sierra Leone.
To the Western eye, there is something jarringly incongruous, even shocking, about the image of a six-year-old girl being held down by loving relatives so that her genitals can be cut. Yet two million girls experience this each year. Most Westerners, upon learning of the practice of female circumcision, have responded with outrage; those committed to improving the status of women have gone beyond outrage to action by creating various programs for "eradicating" the practice. But few understand the real life complexities families face in deciding whether to follow the traditional practices or to take the risk of change. In The Female Circumcision Controversy, Ellen Gruenbaum points out that Western outrage and Western efforts to stop genital mutilation often provoke a strong backlash from people in the countries where the practice is common. She looks at the validity of Western arguments against the practice. In doing so, she explores both outsider and insider perspectives on female circumcision, concentrating particularly on the complex attitudes of the individuals and groups who practice it and on indigenous efforts to end it. Gruenbaum finds that the criticisms of outsiders are frequently simplistic and fail to appreciate the diversity of cultural contexts, the complex meanings, and the conflicting responses to change. Drawing on over five years of fieldwork in Sudan, where the most severe forms of genital surgery are common, Gruenbaum shows that the practices of female circumcision are deeply embedded in Sudanese cultural traditions-in religious, moral, and aesthetic values, and in ideas about class, ethnicity, and gender. Her research illuminates both the resistance to and the acceptance of change. She shows that change is occurring as the result of economic and social developments, the influences of Islamic activists, the work of Sudanese health educators, and the efforts of educated African women. That does not mean that there is no role for outsiders, Gruenbaum asserts, and she offers suggestions for those who wish to help facilitate change. By presenting specific cultural contexts and human experiences with a deep knowledge of the tremendous variation of the practice and meaning of female circumcision, Gruenbaum provides an insightful analysis of the process of changing this complex, highly debated practice.
This pilot study investigated the mental health status of women after genital mutilation. Although experts have assumed that circumcised women are more prone to developing psychiatric illnesses than the general population, there has been little research to confirm this claim. It was predicted that female genital mutilation is associated with a high rate of posttraumatic stress disorder (PTSD).
The psychological impact of female genital mutilation was assessed in 23 circumcised Senegalese women in Dakar. Twenty-four uncircumcised Senegalese women served as comparison subjects. A neuropsychiatric interview and further questionnaires were used to assess traumatization and psychiatric illnesses.
The circumcised women showed a significantly higher prevalence of PTSD (30.4%) and other psychiatric syndromes (47.9%) than the uncircumcised women. PTSD was accompanied by memory problems.
Within the circumcised group, a mental health problem exists that may furnish the first evidence of the severe psychological consequences of female genital mutilation.
Reliable evidence about the effect of female genital mutilation (FGM) on obstetric outcome is scarce. This study examines the effect of different types of FGM on obstetric outcome.
28 393 women attending for singleton delivery between November, 2001, and March, 2003, at 28 obstetric centres in Burkina Faso, Ghana, Kenya, Nigeria, Senegal, and Sudan were examined before delivery to ascertain whether or not they had undergone FGM, and were classified according to the WHO system: FGM I, removal of the prepuce or clitoris, or both; FGM II, removal of clitoris and labia minora; and FGM III, removal of part or all of the external genitalia with stitching or narrowing of the vaginal opening. Prospective information on demographic, health, and reproductive factors was gathered. Participants and their infants were followed up until maternal discharge from hospital.
Compared with women without FGM, the adjusted relative risks of certain obstetric complications were, in women with FGM I, II, and III, respectively: caesarean section 1.03 (95% CI 0.88-1.21), 1.29 (1.09-1.52), 1.31 (1.01-1.70); postpartum haemorrhage 1.03 (0.87-1.21), 1.21 (1.01-1.43), 1.69 (1.34-2.12); extended maternal hospital stay 1.15 (0.97-1.35), 1.51 (1.29-1.76), 1.98 (1.54-2.54); infant resuscitation 1.11 (0.95-1.28), 1.28 (1.10-1.49), 1.66 (1.31-2.10), stillbirth or early neonatal death 1.15 (0.94-1.41), 1.32 (1.08-1.62), 1.55 (1.12-2.16), and low birthweight 0.94 (0.82-1.07), 1.03 (0.89-1.18), 0.91 (0.74-1.11). Parity did not significantly affect these relative risks. FGM is estimated to lead to an extra one to two perinatal deaths per 100 deliveries.
Women with FGM are significantly more likely than those without FGM to have adverse obstetric outcomes. Risks seem to be greater with more extensive FGM.
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