Background
Female Genital Mutilation/Cutting (FGM/C) or female circumcision is a mutilating procedure which is practised in many regions across the world among ethnic and sociocultural groups, and across religious beliefs such as Islam and Christianity [
1,
2]. FGM/C is defined as, ‘a practice that removes partial or total parts of external female genitalia or causes other injury to the female genitalia for non-medical reasons’ [
3,
4]. Four main types of FGM/C have been described including: (i) type 1 which involves partial or total removal of the clitoris and/or the prepuce (clitoridectomy), (ii) type 2 which involves partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora, (iii) type three or infibulation, which is the most serious and invasive type and involves narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris, and (iv) type four which involves all other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization [
2‐
5].
The procedure is practised in more than 28 African countries, as well as some countries in Middle East, South America and Asia, with prepubescent girls being the main target population [
4]. Global estimates account for more than 200 million FGM/C cases, with Africa including Kenya contributing more than 91.5 million cases [
4,
6,
7]. It has also been reported that migrants from countries where FGM/C is traditionally practised, may continue the practice when they migrate to higher resourced countries, such as United Kingdom, Australia, Switzerland, Canada, the United States, France and Sweden [
8‐
10].
In traditional African patriarchal communities, social norms dictate communal activities and events such as performing FGM/C especially on young women as part of initiation rituals into adulthood [
11‐
13]. Although these practices are meant to bring community members together, including celebrating the passage rites of girls to women, they may be associated with harmful health, psychological and social consequences on individuals, families and communities [
14]. The impacts of FGM/C include short term and long term health complications leading to physical, psychological and socio-cultural problems among affected individuals. Short term health complications include, but are not limited to bleeding, pain and shock [
3,
4], while chronic pain, genitourinary tract infections, damage to genitalia, postpartum haemorrhage, genital tissue scars and keloids, anaemia, and in severe cases, maternal and foetal deaths being the known long term complications [
3,
5,
15,
16]. In addition, FGM/C has been associated with serious psychological problems, such as anxiety, post-traumatic stress disorders and psycho-sexual conditions leading to bodily identity problems [
6,
7]. Some women who have experienced FGM/C have prolonged and/or obstructed labour, which may lead to the development of obstetric fistula(s) [
4]. A vaginal obstetric fistula occurs when a hole (fistula) forms between either the vagina and rectum (rectovaginal fistulas-RVF) or between the vagina and bladder (vesicovaginal fistula -VVF) following prolonged childbirth complications [
17]. Among other complications, a woman with a vaginal obstetric fistula may develop urinary and/or faecal incontinence, leading to severe physical, psychological and socio-cultural problems for the women, their families and the entire affected communities [
18]. Fistulas cause complications such as foul smelling, vaginal and/or rectal discharges, urinary tract infections, dyspareunia and uncontrollable flatulence [
7].
There is some evidence of an association between FGM/C and obstructed/prolonged labour, and a large body of evidence exists for a causal relationship between prolonged/obstructed labour and obstetric fistula [
4,
19,
20]. However, The World Health Organization only presumes that both conditions could be linked in women living with both FGM/C and fistulas, but does not confirm a direct or causal relationship between FGM/C and fistulas.
As already established in existing literature, FGM/C practice is well rooted and grounded in patriarchal cultural and traditional beliefs, but the ideological drivers of FGM/C vary significantly in Kenya by location and ethnicity [
6]. On one hand, the traditional collectivist patriarchal communities practise FGM/C as a way to bring communities together and to celebrate the initiation of young women to adulthood [
11]. On the other hand, the same collectivist and patriarchal societies tend to marginalise women and girls, and as such, women have less power compared to men, who make most decisions, including what can be done to women’s body (e.g. FGM/C) [
14,
21]. The FGM/C practice is usually performed by older women who believe that the procedure will increase women’s attractiveness and marriageability [
11]. The practising women are themselves products of a patriarchal society who perform FGM/C on younger girls to achieve a cultural standard expected for women in such communities [
5,
11,
17]. For many women who have had FGM/C, their traumatic experiences are not discussed and the silence surrounding the traumatic experiences complicates any eradication efforts [
14]. Addressing this and other culturally fuelled social problems requires a deep understanding of the local contexts, including the sociocultural psychosexual, religious and economic factors that perpetuate such practices [
14]. Similarly, the voices of affected women need to be the centre of the discourse and to be used in developing FGM/C preventative strategies.
This paper focuses on stories of three women who reported developing fistulas post FGM/C. The aim is to provide rich insight and perspectives of women’s experiences of living with fistulas linked with FGM/C in Kenya. The paper presents only part of findings from a larger dataset collected for the doctoral program of the second author (GG). The aim of the larger study was to explore the experiences of women living with fistulas in Kenya, experiences that are hidden, inaccessible, suppressed and ignored.
Discussion
Drawing from both the current study findings and the literature, it is plausible to reiterate that FGM/C is a significant public health problem in Kenya, and globally [
2,
42]. Severe infibulation may be associated with serious sociocultural, economic and health complications such as obstetric fistulas [
43], as demonstrated by the women’s stories in the current study.
In addition to direct complications as stated above, evidence exists implicating FGM/C as one of the risk factors for HIV transmission in communal settings, as it involves the sharing of cutting instruments such as knives and razors [
12,
22,
44].
Consistent with the Afro-communitarian ethos, large groups of girls are brought together from networks of close knit communities to undergo FGM/C as part of socio-cultural initiation rite and celebrations [
13]. However, the narratives from Moraa, Sasha and Chemutai, inform of the rejection and isolation suffered by women following the development of vaginal fistulas that they believed were due to the FGM/C. Though FGM/C is a practice that is perceived as bringing the community cohesion, developing complications from the practice might render some women as social pariahs. This rejection and isolation of sick community members is counter to the Afro- communitarian ethos, which embraces communalism. Because of their circumstances such as leaking dirty wastes and bad body odours, these women, not only endure the biomedical complications of fistulas, but also undergo loss of multiple statuses including: the loss of loved ones (e.g. husbands, children, sibling or even parents), extended families, the community and broader social networks. These losses further complicate women’s physical and mental health leading to a further vicious cycle of poor health, poor socioeconomic outcomes and further disadvantages [
45].
Feminist theories would also suggest that the difficulties experienced by the women, contribute in the oppressive structuring that keeps them subsumed and subordinated not only by patriarchy, but by their own difficult existence [
11,
27]. Similarly, traditions such as FGM/C continue to subsume women into an oppressive thinking that enables their own subjugation. The traditional structures operate broadly and reinforce negative attitudes towards women that lead to gendered oppression. As Salami posits [
46], the biggest challenge that African feminists have is to challenge cultural traditions that oppress women, such as FGM/C. This may mean reclaiming the power that women inherently deserve from men. Reclaiming power is necessary because as it is typical in any patriarchal society, men tend to horde most of the social economic and political power, while women are expected to be submissive and subservient [
47]. As described in the stories of Moraa, Sasha and Chemutai, the value of women with fistula is far below that of other women particularly due to their incontinence. With lower literacy, lower or no employability, most have little or no option but to accept their ‘failure’ and status quo, instead of challenging the customs and expectations of their communities, in which they must live regardless of the harms those communities may have caused them. However, as much as the discourses surrounding the debates on FGM/C are necessary, they need to move beyond academic theorisations to an engagement with the women with FGM/C and fistulas.
The FGM/C practice and fistulas not only have significant impact on the individual, families and communities, they also place a significant burden on health systems and should be a matter of public health policy [
2,
31,
34,
42]. FGM/C and fistulas, often lead to patients needing caesarean sections (for those who can access emergency obstetric services), extended hospital stay, and in some instances, the loss of life for mother and/or child [
4,
34]. This comes with significant cost to both the community and health care system which loses productive members of the community to preventable conditions and the cost repairing the fistulas [
9].
Although globally there have been multitudes of efforts to combat FGM/C [
2,
42], addressing FGM/C remains challenging due to its long historical and traditional practice and acceptance. Respected ‘older women’, who are elders/leaders in their communities, and were themselves ‘
victims’ of FGM/C, advocate for FGM/C to be performed on their children and younger women in their communities [
4,
31]. Older women often are in the frontline performing FGM/C due to cultural communitarian ethos and patriarchal system that, as stated elsewhere in this paper, stratify women in order of importance and status depending on whether they have had FGM/C or not. In addition, in some community settings where FGM/C is known to be harmful, efforts have been made especially by ‘caring’ parents and significant others to make it
“safer,” through seeking help from medical professionals, through what is known as ‘
Medicalization of FGM/C’ [
7,
35,
48]. The medicalization of FGM/C has also been a hindrance to the success of public policy and other initiatives against the practice [
17,
18]. Even though it is now common knowledge that FGM/C carries no medical benefits, in some communities, its medicalization has perpetuated the practice due to the high respect afforded to medical practitioners and the false belief that it is ‘
safer’ [
6,
9] when performed by clinicians.
Interestingly, those women who reported that their fistulas were related to FGM/C seemed to do so as a result of direct conversations they had with health workers after developing the fistula. This may imply that there is an underlying gap of information on how FGM/C can cause long term scarring of tissues that can lead to obstructed and prolonged labour. However, we did not specifically examine this issue.
Despite the existence of strong traditions of African communitarian, which provide social networks, identity and sense of belonging to communities [
12], the power inequalities between women and men seem to be problematic in patriarchal communities such as in Kenya. This paper demonstrates that due to such power imbalances and marginalisation of women, FGM/C is practised without considering what harmful impacts it can cause on women and those surrounding them.
To redress these issues, there is a need for a strong advocacy and employment of multiple strategies including involving community education and social change. A complete cultural shift in the way people think about women and their bodies is necessary in order to completely eradicate FGM/C and other similarly injurious practices [
34,
49]. This will involve the collaboration of political, religious and community leaders as well as the involvement of grass root community based organizations to inform alternative methods of ‘initiation’/rites of passage [
31,
49]. In addition, engaging both older and younger women and improving their affirmative responses towards such socio-cultural norms underpinning these practices, would reduce the likelihood of them romanticising this harmful traditional practice that promotes gendered oppressive negative attitudes towards women [
50].
Additionally, community development strategies and community based participatory approaches such as those developed by Paulo Freire, would encourage critical self-empowerment of women [
51,
52]. Furthermore, Freire advocates for critical community practice where members of the community are able to identify institutionalised forms of oppression and derive ways of subverting that systemic power. The community participatory approaches will bring together people with a collective objective to empower the most marginalised persons in the community [
52]. Similarly and consistent with the principles of primary healthcare and the Ottawa Charter [
3,
15], inter-sectoral collaboration involving both health and non-health sectors, using both top down and bottom up approaches, will be required necessitating resource reallocation to ensure that women do not continue to endure such horrific practices in the name of culture and traditions [
15]. Moreover and also importantly, efforts need to be made to educate men–especially on the importance of supporting women who refuse FGM/C. Feminist thinking would suggest that men who exist outside of the patriarchal expectations are more likely to see women as their equal rather than as their subordinate.
This study has limitations including that only a small number of participants’ narratives were presented in this paper. Although a purposive sample was used to interview women living with fistulas in Kenya and identified those who linked their fistulas with FGM/C, the results do not necessarily reflect the experience of all women who have had FGM/C or who are living with fistulas. The study also did not explore issues such as what activities health workers can do to prevent FGM/C and fistulas in their communities. These are important issues that could be explored in future studies.
Acknowledgements
We would like to acknowledge all the women who participated in this study for their honest and deeply vulnerable stories.