by Hibo Wardere
Aside from the genital trauma, constant urinary tract infections and back pain, the list of symptoms experienced by some women after FGM goes on: kidney infections, chronic pain due to trapped or unprotected nerve endings, cysts, abscesses and genital ulcers, chronic pelvic infections, and an increase in genital infections like bacterial vaginosis. In contrast, other survivors report no ill effects as a result of their circumcision – these are the same women, however, who go on to mention in passing that it takes them fifteen minutes to urinate. I imagine these women simply have not connected the pain and discomfort they suffer as an adult to the abuse they suffered as a child, which would not be surprising if they were babies when the FGM took place and were too young to remember it.
One nurse on the front line helping women is my friend and fellow campaigner Joy Clarke. Joy has worked as a midwife at north London’s Whittington Hospital for two decades; fifteen years ago she opened one of the country’s first-ever dedicated FGM antenatal clinics at the hospital.
People have tiptoed around the cultural issues in the past. When I wanted to open a clinic people said, ‘Why are you getting involved? It’s not your culture.’ I remember midwives themselves from Nigeria telling me, ‘I have had it done and I’m OK.’ But my responsibility has always been to the woman and the baby, to make her life better. We’ve come a long way, but people still question the need for an FGM clinic. But I don’t care – at the end of the day I need to save lives.
Joy sees women every day who have suffered Types 1, 2 and 3 FGM. But, she says, often the problem is that the women themselves don’t understand what has been done to their bodies. Dr Comfort Momoh agrees: ‘What people need to realise is that some of these women have had complications all their lives, but they don’t physically relate the complications to FGM. It’s just something they’ve lived with.’
It is only in recent years that awareness of FGM has risen in the public’s consciousness. Having been under the social radar for years, it has since become a much-discussed subject – this is unquestionably a positive thing, but one of the outcomes of this new focus is that suddenly survivors are under society’s spotlight, and they’re being told that the way they look is wrong. Research has revealed that many migrant women are anxious about seeking help once they arrive in this country for fear of being judged by medical professionals here, and I can identify with that. I was terrified to open my legs to a doctor for the first time and allow her to see what had been done to me. That’s something we need to bear in mind – we must not isolate these women further. Clinical psychologist Amanda O’Donovan says she has seen some of the negative results of media campaigns labelling FGM as child abuse in British newspapers.
For some women who’ve come to my clinics it was the framing of it as child abuse that they found upsetting and difficult because they had made peace with their bodies. Obviously there is a political and social will to end this practice but there is a need to balance the campaign to end the practice with an understanding of the woman’s individual experience, because out of a global population of millions who are being cut, not every woman will be carrying psychological damage.
Research on just how much women do suffer psychologically with the effects of FGM is still ongoing; personally, I’ve woken up sweating and screaming in the night from recurring nightmares my entire life. These and the flashbacks I experience in my waking day can be debilitating in themselves. I’m certainly not alone. There is evidence that women suffer unbearable psychological consequences as a result of undergoing FGM. Post-traumatic stress disorder (PTSD) is often high on the list of how women are affected. A Manchester study found that 75 per cent of women who’d suffered FGM admitted having the same recurrent and intrusive memories of the event.24 In Egypt, 94.9 per cent of women reported emotional trauma of some kind.25 And in 2012, a UK study by the New Step for African Community project reported the long-lasting emotional damage left by FGM on those interviewed, particularly the difficulty they felt of suffering in silence. That’s what I remember, the loneliness of suffering in a community where everyone is cut and yet no one talks about it.
A 1992 study looking at the psychosexual difficulties experienced by women who’ve undergone FGM found that anorgasmia (inability to orgasm) was regularly reported.26 Likewise another study in 2001 found that 80 per cent of women reported ‘significant sexual difficulties’, with 45 per cent reporting a lack of desire for sex, 49 per cent reporting reduced pleasure and more than 60 per cent of women saying they were unable to orgasm.27 Being sewn up makes sex in itself practically impossible; some healthcare workers insist that unless a woman has been opened, she cannot achieve full penetration through an infibulated vagina and a man alone cannot open her due to the rigid scar tissue. Where this is the case, it is thought that a woman gets pregnant when a man ejaculates at the opening of her vagina and the sperm swims up to her cervix.
Either way, as a practice that is primarily carried out to prevent women from having or enjoying sex, it is wholly effective. I’ve found it impossible to enjoy an intimate life with my husband, not only perhaps because my clitoris has been removed and is still covered, but mostly because of the psychological trauma. I can only speak for myself of course, but I have only ever associated my vagina with pain and trauma. Naturally, that upsets me deeply, because how can my husband enjoy himself when he sees how much I suffer? I have been denied the basic right of a healthy sex life and I believe there are many women who feel as I do. The brutality of what took place between our legs would obviously leave its mark, and yet that doesn’t stop any of us craving intimacy with the men we love. For me, it’s impossible for it not to have a negative impact, although I am aware that there are plenty of FGM survivors out there who report that they do have a good sex life. Of course, one woman’s experience can differ so much from another’s and it’s impossible for one woman to speak on behalf of all FGM survivors.
Increasingly in Britain, clinics like those run by Joy Clarke and Dr Comfort Momoh are seeing women who, like me, wish to be ‘opened’ before marriage. For some women, like Fatuma Farah, part of coming to terms with what has happened to them psychologically involves this physical process of deinfibulation too.
For me, the most damage FGM caused was the relationship with my mother, but at the end my mother passed away, and whatever happened between us, I forgive her. But I’m still left with myself, so something had to happen within myself and my body to end what had begun. For us FGM victims, the morning that we were cut was the beginning of something that has to end somewhere, and that ending has to come in the way it began, with a reversal operation. Something has to happen to our bodies to get closure. Of course to different women it means different things. But for me it was having the operation and convincing myself that I could make my vagina look as natural as I could. Also, for me, marrying someone from an FGM-practising community and him accepting my body for what it is was a huge part of the healing process.
Not every woman feels the same about their deinfibulation, though, and Amanda O’Donovan warns that, for some, more surgery on that area can be extremely traumatic in itself.
For many women it can be an act of reclaiming their body, but one patient who had a reversal done was actually really upset and traumatised by it. She couldn’t remember her FGM, but she had images of what it might have been like and that sense of starting again with the deinfibulation was just as traumatic for her. It is not a reversal because it’s not possible to return your body to the way it was when you were born. Some women feel, ‘Now I’m just surgically altered in a different way,’ and that’s another change to process. A lot of women do feel very empowered though, having made that step, and feel like their bodies look like they do because of something they’ve chosen to do, rather than something that was done to them without their choice or consent. And, of course, when deinfibulation resolves any reproductive, gynaecological or urinary issues, that’s really important for the woman’s health and wellbeing.
For o
thers, there isn’t much that doctors can do, as they can’t restore flesh that has been taken away. At the reversal clinic in Tower Hamlets, she has also come across cases where reconstruction has not been clinically appropriate, and some women can experience this as another loss – they have come to the clinic hoping that it can all be undone and are told that unfortunately it can’t. What Amanda is keen to stress is that any kind of deinfibulation achieves the best results when it is treated in a holistic way, addressing both the medical side and the psychological side.
Taking that next step to deinfibulate myself completely is not something that I’m willing to go through now. It’s possible that I might never feel ready. For me, there is a barrier in my mind when it comes to that part of my body, and I worry that any kind of surgical procedure in that area might trigger the trauma of the cutting and the memory of the pain as I slowly healed the first time. Even today, when I have an infection down there I find it difficult because it is another thing that triggers terrible memories. To some extent, perhaps I have divorced myself from my own vagina. But perhaps it is time to finally make friends and reconnect. And there are a lot of people out there to support me, and other women like me, in starting that process.
At her clinic at St Thomas’ Hospital in London, Dr Comfort Momoh carries out deinfibulations every single day. Surprisingly, in her clinical experience, 50–60 per cent of women who have had Type 3 FGM do still in fact have an intact clitoris underneath their scar tissue, so a procedure can be done to expose it, allowing the patient some sensitivity around the area during sexual intercourse. Obviously this is very positive news for survivors. There is still a relative dearth of information and research when it comes to FGM, but Comfort’s theory for why the clitoris is still present in such a significant number of cases is that it comes down to a lack of anatomical knowledge in the village circumcisers – they might not know what the clitoris or the labia actually are; they just know that they have to remove certain things from the body. Comfort has worked with communities from different countries, and she believes that in those where FGM is performed on girls as babies, there is little that is obvious to remove. Perhaps, then, what takes place is only a partial clitoridectomy, and as the baby develops, whatever is left develops too.
I also tend to think that the circumcisers are not stupid. They have done this for many years – some might have been circumcisers for thirty or forty years. It is their job and their livelihood, and perhaps they are aware that, because of the vascularity around the area, a girl can bleed to death if you remove the clitoris. If they remove the less vascular area, which is the labia, and then cover everything together, the cutter has still satisfied the cultural needs of the procedure.
It is not just Comfort who has reported this finding. A few years ago, American gynaecological surgeon Dr Marci Bowers started working with Clitoraid, a charity that seeks to help FGM survivors all over the world to undergo reversal operations. It should be mentioned here that this charity has courted some controversy because of its links to the Raëlian religion, which backs it. Raël preaches that humans were created by extraterrestrials to enjoy untrammelled sexual pleasure, which indeed does raise some eyebrows, and yet there is no doubt that the cause they’ve taken up helping FGM survivors is a noble one, so it’s worth hearing what they have to say. Dr Bowers is keen to point out that she is not a ‘Raëlian’ but a doctor, and since her training was sponsored by the organisation she has performed reconstructive surgery on 150 patients, many of whom had travelled from Britain to her clinic in California for help, for which she does not charge. Like Comfort, Dr Bowers has noted that a full reconstruction isn’t always necessary – one in five of the women she sees has a clitoris that is completely intact. ‘The cutters are not trying to injure the girl, they are doing it as a rite of passage. These are often their loved ones, their friends’ children, their nieces. They are doing it to control sexuality, and they know not to go very deep and put the girl’s life in danger.’
Dr Bowers gained her expertise from training with the pioneering and well-respected French urological surgeon Pierre Foldès, who developed a technique that would help reconstruct victims of FGM. Like many doctors, before she joined Clitoraid, Dr Bowers had very little understanding of what FGM is, and was sceptical about the possibility of clitoral reconstruction, in part due to having only a superficial knowledge of the nature of the clitoris.
FGM is not as destructive medically as you first think because what it does more than anything is obscure the clitoris by burying it under scar tissue. There is a lot of clitoris, it isn’t a 2mm piece of tissue, it’s much larger – just as in males, where the erogenic area of the pelvis when mapped out is much larger than advertised, so the clitoris is literally the tip of the iceberg. There is an 8 per cent mortality rate overall from FGM – the cutters know only to go very superficially, mainly removing the labia minora and the clitoral hood, and not to go too deeply into the clitoral body. The clitoral body is where most of the sensation is from, so the reversal process means we’re trying to locate that clitoral body and bring it to the surface. You just need to dig beneath the surface and it’s always there, one hundred per cent of the time.
Prior to talking with Dr Bowers I’d had no idea just what a huge and deep organ the clitoris is. ‘It just goes to show that such superficial attention is paid to a woman’s sexuality,’ she says. ‘Socially and globally, people just don’t talk about it. This is due to vestiges of past Victorian attitudes which are dismissive of women’s sexuality, but if you understand that area of the body then you realise that there is so much more to it. We shouldn’t be so afraid of it.’ Dr Bowers admits that reconstructing the labia isn’t always possible – once skin is gone, after all, it’s gone. For her, finding the clitoris is, in her words, ‘the money spot’. However, while surgery offers so much hope to women, she’s also very mindful of the trauma it can cause too, and acknowledges that the reactions of patients vary from individual to individual.
Women don’t usually come forward because they want any kind of restoration of pleasure; they come forward because they feel their identity was stolen by FGM. They want to reclaim their identity, and many psychological effects can be gained by doing that – they receive validation for what they went through; it can be an opportunity to connect with other women who have gone through it; they can often feel more engaged sexually after surgery. But women can find it difficult too; they can be surprised by the sensations that they are left with because the clitoris is fairly unprotected and they can be surprised by how sensitive that area is. Mostly that can be a good thing, especially if prior sensations in that area were associated with negative feelings. It’s very complicated because there is also a risk of re-traumatising women.
It’s important, therefore, that women also have psychological support when they go through any kind of reconstruction; although Dr Bowers offers her surgical skills for free, and a number of psychotherapists have offered their time to her team, it can still be harder to secure as much voluntary psychological assistance as she would like. Nevertheless, the fact that this service is free is an acknowledgement of how important this issue is worldwide. ‘We don’t charge patients because Pierre Foldès did not charge for his work,’ says Dr Bowers. ‘He feels FGM is a crime against humanity so therefore it would be unethical to charge for reconstructions. In my work I’m able to pay my bills through other means. It’s a beautiful thing to be a part of.’
Thirty-eight-year-old Pamela Okah-Bischof from Nigeria is one of those women living in Britain who has sought reconstructive work. She says that undergoing this surgery was, for her, a way of resolving the anger she felt at the fact that she had been subjected to Type 1 FGM when she was a young girl.
I remember clearly what happened to me. I was eight or nine at the time. I had been sleeping that morning in my brother’s room because I had watched a movie that was scary the night before and I didn’t want to sleep alone. Between 5:30 and 6am, my father and stepmother
came to get me out of my brother’s room. My father told me I was going to do what my sisters had done and I was going on my journey towards being a woman. I said to him, ‘What does it mean to be a woman?’ and he said, ‘Don’t worry.’ There were two hefty women there and one smallish one, and she carried the little bag with her. They asked me to go into my room and already there was a mat on the floor. They asked me to take off my bottoms and lie down, and just as I hit the floor the two women jumped me. One of them sat on my chest and held my arms down, the other two tore at my legs . . .
I didn’t think anything about FGM as I was growing up. At first, when it happened, I didn’t think about culture or anything like that. For me at that time FGM was not a crime; it was just something they had to do to you. It was later on when I started having the flashbacks, and when I came to the UK and I started to research it, that I had a lot of anger issues. I didn’t care that it was a traditional or cultural thing – my father was a very educated man and I didn’t expect that he would have gone down this route. For me there was a lot of anger, but my father passed away so I never had the opportunity to speak to him about it.
Pamela’s way of dealing with the anger was to take back control of her own body by searching for help. She attended Comfort’s clinic, where they cut open the scar tissue over her clitoris in order to expose it. But this, for Pamela, was not enough of a reversal. She felt something had been taken away from her and that perhaps someone could give it back. It wasn’t about her sex life – she had always been able to orgasm – but about her psychological wellbeing. As a midwife, she sees vaginas on a daily basis, and she wanted to be able to look at herself and feel that she also had a normal vagina. ‘If I didn’t know what normal was it wouldn’t have been an issue for me, but for me it was done at an age when I remember so many things and I can’t forget what happened. It was the fact that I knew something had happened that was killing me more than anything else.’
