Category — Blog

Pakistan National Women’s Health Forum Highlights Efforts to End Obstetric Fistula

I had the honor of speaking at The Pakistani National Forum on Women’s Health (PNFWH), held during the week of March 4^th, 2011 in Karachi.  The event featured renowned experts in reconstructive pelvic surgery, fistula treatment and women’s health from the Middle East, Africa, Europe, Asia and North America.

Based in Pakistan, PNFWH’s mission is to improve the quality of life for women regardless of race, creed or economic status.  Its holistic approach targets particularly those who would typically fall outside the reach of the benevolent hands of healthcare efforts – women who live along the rural areas and urban slum. The slogan of PNFWH is “Neglect No More, Dignity Restored.”

A fistula is an abnormal hole between the vagina and the urinary tract or the vagina and the rectum.  Fistula most often results from prolonged labor, where the woman cannot deliver the baby, often pushing for days and days before arriving for medical care. Once the baby is delivered, usually a dead baby, the delicate vaginal tissues that sustained all the pressure of days of pushing manifest the damage, resulting in fistula channels that allow the uncontrollable, constant passage of urine or feces through the vagina.

In many developing nations throughout Africa and Asia, where obstetric care is minimal or absent, obstetric fistulas are common and may be quite large.  Obstructed labors not only cause fistulas, it is not uncommon for a baby to be born dead under these circumstances, and for pelvic nerve damage to result in permanent foot-drop, making even the simple act of walking forever difficult for these women.

PNFWH joins with other civil service agencies, including United Nations Population Fund (UNFPA) to stand up for women’s rights and their health, empowering them to achieve their full potential in today’s society. In 2006, it’s Fistula Project aimed to do this by improving maternal health, decreasing maternal morbidity and disability, and rehabilitating women who suffer from the ‘aftershock’ effects of pregnancy and childbirth.

What does PNFWH look like in action?  The UNFPA-funded Fistula Project established seven regional and five referral Fistula Repair Centers that service women from all Pakistani provinces.  The free services include training of midwives, making quality surgery accessible to all patients by arranging reach-out camps and providing necessary transportation. Under these efforts, more than 2,111 fistulas were repaired with an impressive 93% success rate, restoring dignity to these patents  PNFWH promotes awareness and prevention of fistulas by advocating better childbirth practices across the globe.

To join the effort to end childbirth fistulas, or to learn more about PNFWH and UNFPA, visit

Pakistani National Womens Health Forum & United Nations Population Fund

Welcome to Grand Rounds May 3, 2011, the official blog of Better Health: smart health commentary.

This week’s medical blog sampler brings you fresh perspectives on

INTERNATIONAL HEALTH

A preview of the final act - Dr. Mariana Perroni in Haiti

Semen and Scandal, American Style:

We open with a classic “America, Land of the Hypocrite, Home of the Knave” perspective on the downfall of University of Michigan Professor Emeritus, Lazar Greenfield MD, brought to us by Laikas Mediblog, a medical librarian exploration from the Netherlands entitled How a Valentine’s Editorial about Chocolate & Semen Lead to the Resignation of Top Surgeon Greenfield.

Renowned for the Greenfield caval filter, Dr. Greenfield terminally undermined his career after alluding to published data on the mood enhancing effects of sperm exposure in one of his many editorials published in Elsevier’s throw-away, Surgery News. Seriously, what is UP with us in this country? From ABC news to the NY Times to the Huffington Post to the Association of Women Surgeons, this pre-eminent surgeon suffered an horrific public skewering for these (if you ask me, the most it warrants is a short chuckle and a Brooklyn-style rolling of the eyes) words:

“So there’s a deeper bond between men and women than St. Valentine would have suspected, and now we know there’s a better gift for that day than chocolates.”

The feeding frenzy of self-righteous, “Oh no he didn’t”  mayhem was squelched only by the resignation of one of the living legends of our medical times. Once again, American culture perpetuates utter bewilderment from the other side of the pond. Thank you, Laika.

Travel Clinic: Safeway saves the day

Dr. Pullen makes it easier to grab your passport and flee to saner shores, spreading the good word on the merits of Travel Clinics located in Safeway Pharmacies. Run, don’t walk, to your nearest Safeway for convenient, cost effective travel screening and medical preparation on the spot for a fee I, I’m tellin’ ya, you’ve got to see it to believe it, this decimal point warrants a double take.

Psychosis: don’t let it make you crazy

Once you”ve made your post-Safeway escape, should you find yourself in Holland and suffering your first psychotic break, which, if your name is Lazar Greenfield, MD, may well be the case, W.W. van den Broek, MD, PhD suggests you never wean from your anti-psychotic regimen, lest you suffer a relapse, which, apparently you will, per the recently published PhD thesis of Geartsje Boonstra on the continuation of medication (good idea) compared to weaning from medication after a period of stability (not so good, apparently).

Afghan women and U. S. Marines – not so different, actually

While perusing van den Broek’s Dr Shock: a neurostimulating blog I came across another irresistible posted video on the U. S. military’s ingenious use of female troops to “win the hearts and minds” of Afghan women suffering the terrors of home-grown gender apartheid.  Just watching it made me healthier. Thanks, W. W.

Haiti

Medical Practice Manager extraordinaire, Mary Pat Whaley, shares a post submitted by her consultant, Donna Izor. Donna worked in Haiti, taking her nursing skills out of 20 years in mothballs in order to “Do what you can, with what you’ve got, in the moment you’re given”. My favorite part… they started in the neighboring Dominican Republic at La Romana, one of the premiere resorts of the West Indies. I’ve ridden the polo ponies of ambassadors at La Romana. What a culture-warp! In the end, she found it painful to leave Haiti, a testament to the powerful humanity of Haitian people. More on that later…

Canadian Healthcare

From David Williams, co-founder of MedPharma Partners LLC, we get an outsider’s inside perspective on  the merits and demerits of Canadian Healthcare gleaned from time spent working and living among our friends North of the Border. Guess what? Pandering in Media happens everywhere. Shocking.

Cosmetic breast surgery & breast cancer screening

Ramona L. Bates MD,  plastic surgeon with a blog-habit, brings us squarely back to some State-Side reality with her entry on the poignant under-utilization of breast cancer screening prior to cosmetic breast surgery all too painfully common among a survey of American cosmetic surgeons. A wee bit alarming, frankly.

Haiti (re-verb…)

And with great pleasure, I bring you the most endearing of entries,  sent by email for direct posting of content and images, by Mariana Perroni, MD, Physician (Intensive Care and Internal Medicine) and Social Media Specialist at Albert Einstein Hospital, São Paulo, Brazil. She writes: “I wrote the following post for my hospital blog in February 27, 2010, while working as a volunteer in a field hospital in Haiti. It was called Love a Child Recovery Center and it was run by us (Albert Einstein Hospital – São Paulo – Brazil), Harvard Medical School and University of Chicago Medical School. ”

Haiti. Courtesy Dr. Mariana Perroni

We have, according to the census, 39 patients under our care today. This amount represents 15% of the total number of patients in the field hospital. Still, the number of family tragedies is uncountable.

While entering one of the tents during the morning rounds, I laid my eyes on a skinny and smiling 15 year young man. Some locals had already told me that this boy was trapped under the earthquake wreckage for days, with his family. And that both him and his father were forced to watch the slow and painful death of his mother, while stuck in the ruins. When they finally managed to escape, they carried the corpse for three days aimlessly through the destroyed streets, searching for a decent place to bury her. Being unable to find one, they were forced to make one of the toughest decisions of their lives: leave her in the street and move forward in the struggle for survival.

When I asked the young man how he felt, he answered “God wanted this to happen in my life for a reason. I am very grateful for having had the chance to continue to living it. I’m fine. “ And, on my way out of that hot and dusty tent, I heard father and son heard chanting a prayer with excitement.

It was then, amidst all that dust, pain, mutilation and misery, when I realized the powerful presence and importance that music has on the lives of the people in Haiti. The sound of melodies is constant. Whether in tents, where families spend time and distract themselves from the pain while singing songs about hope; in the streets, where women motivate themselves to do their laundry chanting prayers in unison; in the tiny radios inside the tents and in the night meetings, where the locals sing, pray and dance, with or without crutches, with great enthusiasm. Much more than vitamins and painkillers, I conclude that musical notes are the most power and effective adjuncts to the treatments performed here.

I couldn’t help but remembering the words of Aldous Huxley, who said that “after silence, music is what comes closest to expressing the inexpressible.” In my second day in Haiti, I am beginning to doubt it was him, and not a Haitian, who said that.

In the OR, UNFPA Fistula Center, Karachi, Pakistan 2011

Welcome!

The theme for May 3, 2011 Grand Rounds is International Health -

Have a story to share about your experience working abroad? Research or program development in international health? A personal tale of being an actual patient outside the States? A cross-cultural perspective gleaned from patients in your care or your own emigration? A “House” style fascinoma with global overtones? Let’s have it!

Send your posts to drromanzi@urogynics.org

NB: Grand Rounds – the blog of  Better Health: smart health commentary

Sexy = no pull-up Huggies in the ocean

Apr 2011 Journal of Sexual Medicine Literature Review

Handa VL, Whitcomb E, Weidner AC, et al. Sexual Function Before and After Nonsurgical Treatment of Stress Urinary Incontinence. Female Pelvic Med Reconstr Surg 2011;17:30-35.

A secondary analysis of the larger “Non-surgical management of stress urinary incontinence: ambulatory treatments for leakage associated with stress (ATLAS) incontinence” published in 2010, this study of 445 sexually active and inactive women described sexual function in women seeking stress incontinence therapy, compared the impact on sexual function of incontinence pessary alone, Kegel exercise and behavior modification alone, and combined pessary/Kegel/behavior modification, in addition to determining whether or not these non-surgical management therapies for stress urinary incontinence (SUI) improve sexual function.

Women who were sexually active answered 2 validated questionnaires before and 3 months after therapy, both the Pelvic Organ Prolapse – Urinary Incontinence Sexual Function Questionnaire (PISQ-12) that has been validated only in sexually active women in heterosexual relationships, and the generic short form Personal Experiences Questionnaire (SPEQ) that is validated among peri-menopausal women both sexually active and inactive.  The SPEQ total score and individual domain scores of libido, arousal and dyspareunia were included for all women while the sexually active women also underwent PISQ data analysis included total score and questions directly evaluating impact of incontinence on sex; “Are you incontinent of urine with sexual activity?” and “Does fear of incontinence (urine or stool) restrict your sexual activity?”

Women in all three treatment arms were about 49 years of age, mostly white, and evenly divided between pre- and post-menopausal women of normal BMI.  Analysis included women with only SUI and women with mixed stress and urge urinary incontinence.  PISQ scores were lower, indicating lesser sexual satisfaction, the mixed compared to pure stress urinary incontinence group.  Women successfully treated for pure SUI had greater improvement in overall PISQ score, greater reduction of leakage with sexual activity and greater reduction in restriction of sexual activity due to incontinence-related anxiety than did the women not successfully treated, such that improved sexual scores correlated most strongly to whether or not treatment of incontinence was successful.  The improvement in incontinence during sexual activity was greatest for the combined therapy group than for the pessary only group and similarly for the behavior/exercise only group compared to the pessary only group. While pelvic muscle score (Brinks model) was associated with successful SUI therapy, it did not, in turn, correlate to improvement in either the PISQ or SPEQ score. SPEQ scoring did not differ between stress only or mixed incontinence groups except for dyspareunia that was higher in the mixed incontinence group, nor were changes in SPEQ score different in successful and unsuccessful treatment.  The results suggest that consideration ought to be given to Kegel exercises and behavioral incontinence strategies for non-surgical treatment of women suffering incontinence during sex and who restrict sexual activity due to coital incontinence anxiety.

Surviving the Big C sometimes ain’t so sexy, except of course that you’re alive, which is the sexiest of all. But sometimes, often times, it lets all the air out of your tires when it comes to feeling sexy, being sexy, getting your heart and soul around that Marvin-style Sexual Healing.  A recent study in the American Journal of Obstetrics and Gynecology reports on a need for greater attention paid to the sexual and pelvic floor function of women fortunate enough to survive gynecologic cancers.  If you or someone you love sounds like the women in this study, chances are she’ll find help and hope in the consultation services of a specialist in female sexual dysfunction.

Life ain't for sissies.

Apr 2011 Journal of Sexual Medicine Literature Review

Rutledge TL, Heckman SR, Qualls C, Muller CY, Rogers RG.

Pelvic floor disorders and sexual function in gynecologic cancer survivors: a cohort study.  Am J Obstet Gynecol 2010;203;514E1-7.

This questionnaire survey study used the Pelvic Organ Prolapse/Urinary Incotinenence sexual Questnnaire (PISQ-12) along with validated urinary and fecal incontinence and pelvic organ prolapse questionnaires to determine the prevalence of sexual and pelvic floor disorders in a group of women over age 30 with histories of uterine, cervical, ovarian or vulvar cancer, all disease and treatment free for at least one year.

A control cohort of 108 women without cancer histories also completed the questionnaires after chart review matched them to the study group of cancer survivors. Because the study group was far more likely to have undergone hysterectomy (87% vs 26%) and removal of ovaries (82% vs 14%) than the control group, both of which may independently affect sexual function, data analysis was multivariate.

45% of study participants had history endometrial cancer, 29% ovarian cancer, and 22% cervical cancer. 87% had undergone surgical therapy, 35% radiation, and 35% chemotherapies.  Both groups had rates of urinary incontinence and pelvic organ prolapse that were not statistically significantly different. Women with cancer histories did report higher rates of fecal incontinence and also reported greater fecal incontinence bother than cancer-free controls, despite only 40% of cancer survivors reporting being asked by their oncologists about urinary or incontinence symptoms.

Cancer survivors reported lower libido, higher rates of anorgasmia, lower orgasm intensity, less sexual excitement, lower rates of sexual satisfaction and higher rates of negative emotional response to sexual activity with 5 point lower average PISQ scores and lower rates of sexual activity (45% vs 70%) than the cancer-free cohort. The authors speculate that severe changes in body image and hormone function due as a result of radical pelvic surgery, early withdrawal of natural hormones, hormone suppressive therapies, and radiation effects may all play a role in the extra margin of sexual dysfunction reported by the cancer survivors. The authors state that greater attention to pelvic floor and female sexual dysfunction (FSD) conditions is warranted among clinical oncologists working with female cancer survivors to optimize holistic quality of life issues for these women.

It's different for girls...

Does she or does she not; is the epidemic of “female sexual dysfunction” (FSD) fact or fiction? If fact, what’s to be done about it? Is it hormonal, vascular (clogged arteries – think “atherosclerosis of the vulva and clitoris”), muscular, psychological, or some labyrinthine combination of contributors? Or should we say, detractors? The bad news – we’re not really sure. The good news – smart, skilled & talented people on both sides of the debate care deeply, all carefully plumbing the depths of truth and possibility to sort it all out – to whit:

Apr 2011 Journal of Sexual Medicine Literature Review

NB:    Dypareunia = painful sex    Vaginismus = vaginal muscle spasm often preventing sexual intercourse and always painful

HSDD = Hypoactive Sexual Desire Disorder

Sandhu KS, Melman A, Mikhail MS. Impact of Hormones on Female Sexual Function and Dysfunction. Female Pelvic Med Reconstr Surg 2011;17:8-16.

This review article provides a comprehensive overview of current literature, including areas of controversy, with regard to hormone levels and female sexuality. The authors review the available prevalence data, stating that 43% is the number obtained by the original U. S. National Health and Social Life Survey published in JAMA in 1999 that included women who were, per that author, not necessarily outside of normal range, as the “sexual dysfunctions” included things like fatigue from childcare and housework leading to diminished interest in sex that was not necessarily considered pathological, abnormal or bothersome by the participant women.  Nonetheless, that 43% prevalence rate sparked an avalanche of interest in the possibility that lots of women were suffering sexually without access to evaluation and therapy aside from interactive verbal counseling. These authors respond to the rapid evolution of data sets, therapies and claims by carefully reviewing the formal definitions for the DSM-IV diagnoses of HSDD, categories of female sexual arousal disorders, female orgasmic disorders, dyspareunia and vaginismus, followed by a balanced review of the literature on central and peripheral hormone physiology in menstrual and menopausal women, individual reviews of the roles of estrogen and androgens, the current consensus on normal and abnormal hormone values, the impact of hormone therapies with estrogens and androgens, the impact of natural vs surgical menopause, the controversy regarding androgen insufficiency in pre-menopausal women, and a summary table of Conclusions and Recommendations generated by the Female Sexual Dysfunction Committee in 2004. The authors finish by reviewing practical aspects of current therapies for female sexual dysfunction including phosphodiesterase inhibitors,  Tibolone, DHEA, mechanical devices and electric stimulation, both vaginal electric stimulation for vaginismus and the more controversial sacral neuro-modulation implant with its dearth of data. The authors of this comprehensive review article state that while classification systems and therapeutic options continue to evolve, much is lacking with regard to understanding, defining, evaluating and treating female sexual dysfunction.  This is a meaningful review for all clinicians, be they specialists in treating female sexual disorders or general primary care clinicians interested in knowing more about a subject affecting more than ½ of their patient population.

Worldwide, “cesarean on demand” continues to increase. In the hopes of avoiding pelvic floor damage associated with birthing, some women have bought into the the trend for elective cesarean before onset of labor. Called “cesarean on demand” because patients demand it in the absence of a maternal or fetal indication, it’s the obstetric equivalent of Erica Jong’s “Zipless F**k”; the maternity version of having your cake and eating it too.

Well, guess what? Just BEING PREGNANT is a risk for all the unhappiness that pelvic floor mayhem can bring, including incontinence and its painfully un-sexy cousin, pelvic organ prolapse. One beautifully executed study evaluated vaginal anatomy before and after 1st pregnancy in three groups of mothers; one who had an easy vaginal birth, another who had a difficult vaginal birth with deep vaginal tearing that required lots of stitching, and third who, whatever the reason, had cesarean before going into labor. Understand that there are medically legitimate reasons for a woman to have cesarean without labor, such as toxemia (pregnancy induced high blood pressure), placenta previa (low-lying placenta blocking the cervix – natural labor with this condition results in the baby bleeding to death before it can be born), or breech presentation (at least in the States, due to out of control obstetric malpractice and the fact that breeches born vaginally have a small but real risk of birth injury that can be almost totally avoided with a cesarean, breech = cesarean until further notice), to name a few.

Looking at the pelvic floor support of these women after first birth, they found NO DIFFERENCE in moderate prolapse between the three groups. Severe prolapse was equivalent in the two vaginal birth groups and much higher than in the cesarean without labor group. But… the cesarean without labor group had a 5% incidence of severe prolapse – I’m talking cervix sticking out of the vagina prolapse, bladder bulging down pushing the labia apart when you walk prolapse.  Thinking a cesarean is the answer to your “I want to be a mother but I don’t want any physical changes in my body anywhere, especially in my vagina” dreams? Think again…

Here’s the study summary prepared for the Journal of Sexual Medicine:

Handa VL, Nygaard I, Kenton K, Cundiff GW, Ghetti C, Ye W, Richter HE. Pelvic organ support among women in the first year after childbirth. Int Urogynecol J (2009)1407-1411.

Increased public awareness of changes in pelvic floor anatomy related to pregnancy continues to foster the growing phenomenon of cesarean on demand, requested in the hopes of maintaining pre-pregnancy sexual function and reducing risk of prolapse and incontinence, two conditions known to negatively impact sexual quality of life in the majority of women so-affected. The true impact of pregnancy on pelvic support may be due to pregnancy itself, regardless of delivery mode, as stated by these authors; “cesarean delivery as a potential prevention strategy remains unproven.” This study prospectively evaluated the impact of first pregnancy on pelvic organ support of 256 women with three pregnancy outcomes – vaginal delivery without anal sphincter tear, vaginal delivery with anal sphincter tear, and cesarean delivery without labor. Pelvic support evaluation done at 6-12 month post-delivery showed stage 2 prolapse in 38% of women delivered vaginally with sphincter tear, 29% in those delivered vaginally without sphincter tear, and in 21% of women delivered by no-labor cesarean with no statistically significant differences between groups.  It is remarkable that 1/5 of the cesarean patients showed clinically significant stage 2 prolapse.  When looking further at stage 3 (true bulging past the hymen, clearly visible and palpable through the vaginal opening), there was a significant difference between vaginal birth and cesarean without labor, with 5% of cesarean women showing visible prolapse as opposed to 14-15% in both of the vaginal delivery groups.  Still, this 5% bulging prolapse despite non-labor cesarean raises the possibility that optimal patient counseling for women seeking elective cesarean for sexual function and pelvic organ protection may best include the realistic prediction of “a small but real risk bad prolapse even if you undergo cesarean before going into labor”. Letting women know that cesarean is NOT a 100% guarantee of avoiding pelvic floor consequences of pregnancy, along with the other risks of cesarean: peri-op morbidity, increased risk of placenta accreta, and increased risk of uterine rupture with subsequent pregnancies. This work adds to the data revealing that the impact of pregnancy on the pelvic floor may not be thoroughly negated by cesarean on demand.

Level of Evidence: IA

(c) 2010 Lauri Romanzi

Stone age sex toy, built to last

Our dear friends at Betty Dodson central command (www.dodsonandross.com) continue to delight, the latest being their posting on an awesome (truly) anthropologic find – a stone-age dildo replete with carved rib rings and obligatory mushroom cap, lest future generations doubt its purpose.

stone age sex toy found in German cave

And now Dodson and Ross bring us more news – yet another pre-historic sex toy un-earthed intact, pret a porter….

Stone-aged sex toy #2 - the more things change, the more they remain the same...

Durability counts.

Dr. R’s blogpost  A word from the wise on Prolene mesh and your prolapse surgery is featured in the esteemed Grand Rounds Medical Blogsite hosted this week at   FDAzilla by Tony Chen. Included with a dozen or so other blogposts on the complications of interacting with the FDA, we highly recommend a perusal of the participating blogs on topics such as The Great Autism Vaccine Fraud by the “ancient but awesome” Joel Shurkin, Dr. Pullen’s top 6 rules of wicked good medicine, and a A Swedish man forced to amputate his cancer-ridden penis after waiting a year for treatment, to name a few. Enjoy!

January 2, 2011

This past fall, courtesy of beloved colleague Patricia Allen, MD and Womens Voices for Change,  I attended an early premiere of the film “Desert Flower” at the Museum of Modern Art in New York. The English-speaking version is scheduled for U.S. release in February, 2011. A movie based on the true story of Waris Dirie, Somali-born super-model who first revealed the truth about her own circumcision to Barbara Walters (20/20: A HEALING JOURNEY WARIS DIRIE: 07/10/1998), Ms Dirie was subsequently appointed UN Special Ambassador, speaking out against female genital mutilation through the United Nations, World Health Organization, and her own Desert Flower Foundation.

The film chronicles her journey from nomadic childhood to international fame, all underscored by the impact of her ritual circumcision, performed on top of a rock in the desert when she was just a toddler.  Already released in Germany, I highly recommend making time to see this film when it’s released next month in the States.

Women's International Network, founded 1975

I first learned of female genital mutilation (FGM) in the ‘80’s, through the groundbreaking work of Fran P. Hosken, editor of Womens International Network News and author of The Hosken Report: Genital and Sexual Mutilation of Females (first edition 1979). Ms. Hosken presented her work at the First International Symposium on Circumcision in Anaheim California in 1989, explaining that conservative estimates put “84 million women and girls”  undergoing or suffering the results of genital circumcision, mostly in continental Africa, also along the Persian Gulf, Indonesia and Malaysia. More common in Moslem communities, the practice is always tied to rites of passage – a woman cannot marry or become a full member of the community without undergoing whichever version of FGM her community practices. As families from these cultures immigrated to Europe and North America, many sought and still seek to maintain FGM in their American and European-born daughters, with reports of black-market FGM done by doctors and other licensed health clinicians, or carried out ritualistically by other émigrés or family members, often with fatal results.

Fran Hosken paper 1989, 1st International Symposium on Circumcision

Called Infundibulation, Infibulation, Female Circumcision, Female Genital Cutting, or Female Genital Mutilation, it is, by any name, horrific in intent and in fact. Designed to secure virginity by making sexual intercourse impossible, the clitoris may also be removed in the process to provide the additional “benefit” of eliminating and controlling female sexual desire. The degree of excision is dictated by cultural practice, so that women in any given community with all undergo the same sort of genital cutting.

The severity of the excision varies, categorized into 4 methods:

Type I: removal of clitoral hood, tip of clitoral glans, small potion of labial minora

Type II: removal of entire clitoris, part or all of labia minora

Type III: “Pharaonic” – the most extreme – complete removal of clitoris, complete labia minora and most of labia majora, leaving a tiny opening for passage of urine and menstrual blood.

This extreme excision was recorded in Ancient Egypt over 2000 years ago, hence the Pharaonic label.

Type IV vaginal scarring, piercing or nicking that causes the vagina to close

This tie to cultural rites of passage has sparked debates in various political and anthropologic circles regarding the potential for cultural bigotry, concerned that Euro-American standards ought not be applied to these ancient genital practices, pointing out that circumcision of males, normal and for a time almost ubiquitous in the States, illustrated the need to “respect” these practices on females. Women and girls seeking international asylum to avoid such procedures were turned away or held in detention as debates raged (EU Agenda on FGM).

As of 1999, the Fact Sheet on U.S. Intervention on Gender Equality, Equity and Empowerment of Women released by the U.S. Bureau of Populations, Refugees and Migration 1999 contains among its six stated goals; “combat violence against women, eliminate female genital mutilation, and reduce sex trafficking”. How sex trafficking got mixed up with the cloistering impact of FGM, and why sex trafficking is not also in the cross-hairs for elimination (reduction deemed sufficient) is a topic for another day.  A federal acknowledgement of FGM as a wrongful act was a hard won step in the right direction, no matter its bedfellows.

The gripping ritualistic mandate and physical horror are captured equally in these excerpts on infundibulation practices in Somalia and Nigeria from the 4^th edition of The Hosken Report:

Middle-East-Info.org: Hosken Report excerpt 1993

SOMALIA CASE REPORT: In Somalia, infibulation is practiced by the entire population –indeed by all ethnic Somalis wherever they live. This practice has existed for as long as anyone can remember and is recorded in the earliest historical accounts (see “History”). Though it is traditionally called “circumcision “, the extreme form of the mutilations to which little girls are subjected is not accompanied by any rituals, festivities, or celebrations such as is done traditionally in Sudan or other African countries designed to disguise the harshness and brutality of the violence.

Here below is an eyewitness account of what is done to all Somali girls because men still today refuse marriage with an uninfibulated, or what is called “open”, bride. And without marriage there is no future for a girl:

“With the Somalis, the circumcision of girls takes place in the home among women relatives and neighbors. The grandmother or an older woman officiates. At each occasion, usually only one little girl or at times two sisters are infibulated; but all girls, without exception, must undergo this mutilation as it is a required for marriage.

The operation itself is not accompanied by any ceremony or ritual. The child, completely naked, is made to sit on a low stool. Several women take hold of her and open her legs wide. After separating her outer and inner lips, the operator, usually a woman experienced in this procedure, sits down facing the child. With her kitchen knife the operator first pierces and slices open the hood of the clitoris. Then she begins to cut it out. While another woman wipes off the blood with a rag, the operator digs with her sharp fingernail a hole the length of the clitoris to detach and pull out the organ. The little girl, held down by the women helpers, screams in extreme pain; but no one pays the slightest attention.

The operator finishes this job by entirely pulling out the clitoris, cutting it to the bone with her knife. Her helpers again wipe off the spurting blood with a rag. The operator then removes the remaining flesh, digging with her finger to remove any remnant of the clitoris among the flowing blood. The neighbor women are then invited to plunge their fingers into the bloody hole to verify that every piece of the clitoris is removed.This operation is not always well-managed, as the little girl struggles.

It often happens that by clumsy use of the knife or a poorly-executed cut the urethra is pierced or the rectum is cut open. If the little girl faints, the women blow pili-pili (spice powder) into her nostrils. But this is not the end. The most important part of the operation begins only now. After a short moment, the woman takes the knife again and cuts off the inner lips (labia minora) of the victim. The helpers again wipe the blood with their rags. Then the operator, with a swift motion of her knife, begins to scrape the skin from the inside of the large lips.

The operator conscientiously scrapes the flesh of the screaming child without the slightest concern for the extreme pain she inflicts. When the wound is large enough, she adds some lengthwise cuts and several more incisions. The neighbor women carefully watch her ‘work’ and encourage her.

The child now howls even more. Sometimes in a spasm, children bite off their tongues. The women carefully watch to prevent such an accident. When her tongue flops out, they throw spice powder on it, which provokes an instant pulling back.  With the abrasion of the skin completed according to the rules, the operator closes the bleeding large lips and fixes them one against the other with long acacia thorns.

At this stage of the operation the child is so exhausted that she stops crying but often has convulsions. The women then force down her throat a concoction of plants. The operator’s chief concern is to leave an opening no larger than a kernel of corn or just big enough to allow urine, and later the menstrual flow, to pass. The family honor depends on making the opening as small as possible because with the Somalis, the smaller the artificial passage is, the greater the value of the girl and the higher the bride-price.

When the operation is finished, the woman pours water over the genital area of the girl and wipes her with a rag. Then the child, who was held down all this time, is made to stand up. The women then immobilize her thighs by tying them together with ropes of goat skin.

This bandage is applied from the knees to the waist of the girl and is left in place for about two weeks. The girl must remain lying on a mat or the entire time while all the excrement evidently remains with her in the bandage.After that time, the girl is released and the bandage is cleaned. Her vagina is now closed – except for a tiny opening created by insertion of a straw or reed and remains closed until her marriage.

Contrary to what one would assume, not many girls die from this torture. There are, of course, various complications which frequently leave the girl crippled and disabled for the rest of her life.”

NIGERIA CASE REPORT: A survey by the federal Ministry of Health gives an overview of the current status ofFemale Circumcision in Nigeria as FGM is locally called. This official document of March 1981 is signed by Dr. O. A. (Mrs.)Adelaja, Senior Consultant/Medical Statistics and gives an overview of the situation:

“According to the response obtained from questionnaires completed by most Nigerian states, female circumcision is still being practiced in most states of this country. It is practiced mostly on babies and small girls of Christian and Muslim parents. But certain tribes perform the ceremony when the female is ready to wed or when the first pregnancy is about seven months. Very few tribes perform the ceremony after marriage and in such tribes, it is the duty of the husband to perform the operation.”

Next, the circumstances of the operations are described:

“The ceremony is usually performed on a group of girls, though some report that individual girls are circumcised in their respective homes. A token fee is paid and ranges from two naira to ten naira. The operator may be a man or a woman. Male operators usually perform it as a business and circumcise male children as well. Tools in use vary and include a small knife, a sharp blade, or a razor.

Post operative management also varies, some report hot fermentation with charcoal daily and feeding with roasted meat and some gruel. Snail juice and palm oil are poured on the incision by some. Native soap and native medicine are also used by another tribe.

Complications: Some deny any complications. But among those who admit complications, bleeding is the commonest problem reported. Other complications include tear, septicaemia, fistula, stenosis, delayed second stage labor, tetanus, urinary obstruction, and dyspareunia.

Reason for Circumcision: The majority attribute the operation to age-old custom, culture and tradition. Some claim that circumcision will prevent promiscuity and reduce sex urge, while others believe that if the newborn baby’s head touches the clitoris, such a baby will die.

Death-by-clitoris, or “mythology run amok”, take your pick.

The medical community appears to have caught up with pioneers like Fran Hosken of Women’s International Network and Molly Melching of Tostan, with corroborating research data, including findings just out this month from Kuwait University and King Faisal University in Dammam, Saudi Arabia showing the persistence and devastation wrought by this brutal tradition. (Female Circumcision:…Unabated in the 21st Century) 4800 pregnant Kuwaiti and Saudi women were evaluated for FGM over a four year period. The prevalence Female Genital Cutting was 38%. Circumcised women had longer hospital stays, higher rates of prolonged labor, cesarean delivery, hemorrhagic bleeding, death of the newborn, and hepatitis C. Flashbacks to the cutting event were reported by 80%, 30% met criteria for post-traumatic-stress disorder relating to the cutting event, 58% had major psychiatric disorders, and 38% had chronic anxiety. These researchers conclude that “Female circumcision is associated with adverse materno-fetal outcome and psychiatric sequelae. Many will need psychiatric as well as gynecological care.”

Compulsion to participate in community ritual can be both bizarre and fierce, as illustrated in the 1989 book Our Grandmothers Drums by Mark Hudson. In 1985, the author worked in a Dulaba village in Gambia, West Africa, “where the women are bound by Islam, female circumcision and subservience to their mothers and men”.  In this village, a British-borne aide worker’s teen daughter, who had been born and grew up in the village, was reportedly so enthusiastic to go through the entire ritual of her home-community that her mother was forced to lock her in her room for the entire weeks-long affair to prevent her daughter from voluntarily submitting to FGM, an integral part of the ceremonies.

And therein lies the key – the divorcement of these crucial rite-of-passage rituals from the brutal practice of female genital mutilation. While important, no amount of legislation in the countries where FGM is practiced will eradicate FGM from the remote, poor communities who hold it dear unless the people themselves want it so.
Enter TOSTAN. Tostan is the Wolof word for “breakthrough” and “spreading and sharing”. Founded in Senegal by Molly Melching (U.S. expat) in the 1970’s, Tostan’s track record of success in eradicating FGM cannot be overstated. Working with the communities for literal decades, Tostan’s premier FGM abandonment break-through started with a single Senagalese village in 1997. Since that first group of village women came forward to publicly declare the end of FGM in their community, 4854 more villages in 5 countries (Senegal, Guinea, The Gambia, Burkina Faso and Somalia) went on to eradicate FGM from their rites, rituals, ceremonies and marriagability mandates. This number recently broke through the 5000 mark, as a 3 year Tostan initiative was celebrated by an additional 700 Senegalese villages abandoning FGM on November 28, 2010 :

700 Senegalese Villages abandon FGM

“Aset Mballo, a mother of four from Saré Bidji, declared with her village for the second time. Like many of those present, Aset had participated in Tostan’s Community Empowerment Program (CEP), hailed a “revolutionary approach” by Senegal’s Director of the Family – Ndeye Soukkeyna Gueye – in her speech at the declaration.

The three-year-long Tostan program is taught in local languages and offers human rights-based education focused on democracy, problem-solving, health, literacy and management skills. “I’m here today to teach children and parents about the health problems that are caused by female genital cutting and child marriage. My daughters will not be cut, and I want to bring an end to these practices everywhere!” said Aset.”

Thank you Fran Hosken, Thank You Molly Melching, Thank You Waris Dirie.

What better time for the English-version debut of “Desert Flower” than now?

(c) L. Romanzi 2011