By Hilary Burrage
What an experience this visit to Washington DC turned out to be! Angela Peabody, the Founder-Director of Global Woman P.E.A.C.E. Foundation, made us all so warmly welcome as we met again friends and colleagues from different parts of the world, and discussed various issues with some of the leading medical and legal female genital mutilation (FGM) experts in the USA. And we saw the 2017 GWPF nominees receive their awards for outstanding service to end that cruel and harmful traditional practice.
My (post-event) thoughts on what we discussed follow, with a focus on
*Medical ‘vs’ legal understandings
*Male ‘vs’ female circumcision (MGM and FGM) and human rights / bodily integrity
*Patriarchy incarnate, eg FGM and child, early and forced marriage (CEFM)
*Post-traumatic stress disorder (PTSD)
*Data on FGM prevalence
*Surgical and other treatment and support for FGM survivors
*’Market segmentation’ to maximize the impact of #EndFGM programmes.
For some of us arriving earlier the visit began on Thursday 19 October. French lawyer Linda Weil-Curiel, with Dr Pierre Foldes and Frederique Martz who founded the Paris sexual health institute which serves women with FGM, and I, met with attorneys and other colleagues of Susan Masling in the Department of Justice and FBI programs to end FGM in the USA, before moving on to an evening event at the George Washington University Milken Institute School of Public Health.
Those three excellent sessions raised a lot of questions. My thoughts….?
On both sides of the Atlantic there remains a significant divergence of perspective between the legal and medical aspects of addressing FGM.
Clinicians are loathe to report FGM, or may not even know that in some circumstances the law requires them to do so. This is especially perplexing when one considers that probably almost all legal systems require professionals who are aware a child is at risk to report that risk – which in the case of juvenile FGM may be both to the girl herself, and to any sisters or, eg, female cousins.
Lawyers however continue to maintain that there are few legal cases for suspected FGM-related activity, because clinicians and others such as teachers won’t report their fears. Nor is there uniformity of legislation between all states in the USA or even between the nations of the UK, let alone wider afield around the world.
It is clear that greater mutual understanding and trust is required, and that clinicians need reassurance both about the reliability and security of mandatory reporting routes and about the due care which must be accorded to women and girls who seek help or advice. It seems that adequate processes to accommodate required reporting are widely viewed as not yet in place. This is a matter for legislators and policy to resolve.
The continuing insistence that male ‘circumcision’ – MGM / male genital mutilation – is acceptable is misplaced and muddying the waters.
Circumcision is still routinely experienced by about half of boys in the USA, and it is also apparently acceptable to the most senior judge in the English Family Court.
It is true that the anatomical and physiological impacts of routine Western male circumcision differ in some respects from those of various forms of FGM: Pierre Foldes tells us that eg the embryonic development of the clitoris and its skin / nerves is different from that of the penis.
It is also true that men cannot experience the further risks which women face whilst giving birth. Nonetheless, both MGM and FGM are inflicted most often on juveniles who cannot give consent, and in each case there is exposure to risk.
Nonetheless, in non-Western countries where genital mutilation may be imposed on adolescents of both sexes, the male version can be much more perilous – though even one child damaged anywhere is always one too many – than in surgically controlled circumstances.* Penile amputation as a result of traditional practices leads to deaths and deformity every year.**
*Note too however, that sometimes the medicalization of FGM has resulted in more extensive ‘cutting’ than via some traditional methods.
**See also below, re patriarchy incarnate.
Further, there is evidence that in some traditional communities women claim it isn’t ‘fair’ that the men are ‘allowed’ circumcision whilst women are not. This repercussion has not as far as I know been acknowledged or considered in respect eg of using male circumcision to reduce the incidence of HIV/AIDS. What possibly – it’s not clear – reduces the risk for men may increase various attending risks for women.
On human rights, bodily autonomy and public health grounds, if we are serious about eradicating FGM it will be critical to address some of these issues.
The current MGM problem may, however, be similar to that of addressing FGM in communities where almost all women have experienced it: a large number of the senior men in Western societies have been circumcised. But there are a not as yet noted any instances of this personal interest being declared in judicial or legal circles.
(An aside: Linda Weil-Curiel reports that in France defendants in FGM cases were asked, why, if you took your infant sons to hospital for circumcision, did you not do the same for your daughters? Maybe it’s because you know that FGM has been made illegal, whilst MGM has not?)
It is not generally helpful to think of FGM as fundamentally distinct from eg child, early or forced marriage (CEFM). Both these practices are examples of patriarchy incarnate, the imposition of (some) men’s wills on women’s bodies.
We don’t have to look very far to see that patriarchy incarnate exists in all societies – including modern Western ones. This patriarchy, underlying almost all male (and some female) violence against women (and, again, against some less powerful males) must be acknowledged for what it is.
That acknowledgment allows us to perceive FGM, CEFM and other abuse for what it is.
Without the lens which reveals patriarchy we are fire-fighting, not tackling underlying causes.
But to acknowledge patriarchy is, definitively, not to exclude men who want to see justice and equality. And, just as many would argue that male circumcision is also a result of the exercise of male power, obversely women can act on behalf (as agents) of patriarchy.
FGM is the root of many conditions and illness, physical and psychological. It is very likely that some survivors at least will experience the sort of post-traumatic stress disorder (PTSD) also experienced by military veterans.
As Dr Bessel van der Kolk explains in his work on military veterans (‘vets’), PTSD can be a fundamental influence on post-trauma behaviour, sometimes for life. Those who have experienced the trauma are likely to return to it often, to bond closely with others who have also had that experience, and not trust anyone outside that close group.
This well-established PTSD pattern of behaviour is a protection of sorts for stress survivors, but it can also produce further dis-ease. And it produces challenges for anyone who seeks to support survivors back into ‘normal’ (in this case non-FGM) communities. Does it help some women, for instance, if the therapist or counsellor is herself a survivor of FGM; or, in other cases, is a positive more outcome more likely if the therapist is not involved in an FGM-practising community?
And further, what are the implications for legal professionals who must determine what has happened to a person with FGM (or indeed any similar traditional harmful practice)? How can evidence be obtained in the most verifiable (and also, for the interviewee, least stressful) way?
Data on the incidence of FGM in any given location continues to be uncertain or circumstantial. This makes both the formulation of public health policy and eradication enforcement difficult.
The epidemiology and profiling of FGM, and especially of where it was done, to what extent in what demographics, and by whom, is weakened by inadequate proven evidence. In both the UK and the USA substantial estimating and recording data is now the norm. Over time this will reveal more about where the focus of treatment and enforcement programs must be.
But even then problems remain. UK data does not reliably tell us where FGM was imposed (in what location or country), nor almost anywhere do medical and clinical professionals have consistent and straightforward ways to share substantiated information. The actual practice of FGM varies significantly between different communities, not only in respect of severity but also in terms of how it was done; but where can medical and legal professionals go to find the facts?
There is a need for information sharing on the actual physical details of how FGM is inflicted and what therefore the ‘evidence’ is in different places. In the absence so far of routine data sharing between medics and lawyers, this may be an issue for medical anthropologists to address. Prosecutors for instance need to know what exactly medical examiners (as expert witnesses) must look for, if any particular case is to go forward. Ideally this procedure-specific information should be readily accessible to those medical and legal professionals who need it.
We are still in the first stages of determining how best to support women and girls who have undergone FGM. Surgical reconstruction is increasingly requested, and other psychological, pastoral and social aspects are also often at least as important.
In these respects the experiences and observations of four survivors who have been honored by GWPF are especially important. Francess (F.A.) Cole – who revealed that she very recently underwent reconstruction in the care of Dr Marci Bowers – Severina Lemachotoki, Mariya Taher and the much respected Dr Edna Adan Ismail of her autonomous hospital in Somaliland all spoke at various points during our visit about their experiences and how they have coped and want to help others.
And to that must be added the increasing caseload experience shared with us over the three days by the surgeon Dr Pierre Foldes and his colleague Frederique Martz who runs their clinic for survivors of gendered violence in France, and Dr Marci Bowers in the USA.
Three of us took time out later on Friday afternoon for a guided tour of the National Press Club in Washington, of which Diane Walsh is a member (and, like me, also a member of the GWPF Nominations Committee which selects Awardees).
But most of Friday was our time to visit the Global Woman P.E.A.C.E. Foundation offices, when we met GWPF officials and volunteers, and several 2017 Awardees, firstly at the GWPF address and later, for those who could get there, at a delightful pizza supper hosted by Susan Gibbs.
Discussion ranged over many aspects of our work, and how each of us can contribute to making FGM history. There is room for everyone: survivors, community campaigners, lobbyists, carers and other professionals, researchers, policy makers and politicians. But sometimes perhaps these different aspects of seeking justice, amelioration and eradication become blurred.
As with various other very worthy causes, sometimes there is more energy than strategy in moving forward. How can activists of all sorts, with distinctly different perspectives, ensure there is synergy to maximize positive results?
All complex activities encompass many different types of action. It is therefore vital that there be some recognition of the different roles we can all play.
In marketing circles this differentiation is thought of as segmentation – each part of the equation requires specific engagement/s. As one example, the parts most likely best played by survivors and policy makers respectively may demand very different types of skill sets and knowledge.
The potential for greater impact (‘efficiency’) which segmentation of tasks and focus could achieve, thereby ensuring all involved are accorded respect and play to their strengths is still a long way off. Such an approach would require strong central leadership and political and financial clout adequate to support all ‘segments’ of the action appropriately.
The Awards Day itself. This was the day when everyone came together at the National Sylvan Theater, on the Washington Mall. A day when brave survivors spoke of their fierce desire to stop FGM forever, and others – including Keynote Speaker Senator Richard Black of Virginia, who recently steered legislation through his senate – assured us of their full commitment also to this aim.
The Awardees for 2017 were:
Edna Adan Ismail (Education),
Senator Richard Black (Political),
Adama Diaby (Student Ambassador),
Pierre Foldes and Frederique Martz (Medical),
Tobe Levin von Gleichen (Literary),
Mariya Taher (Survivor Activist) and
Linda Weil-Curiel (Legal).
And so we came to the end of our visit.
After the Walk-A-Thon Francess Cole and I had time to chat – I could listen to her amazing story for hours. Then in the evening a group of us continued to talk over dinner, affording time to get to know more about the work of Marci Bowers and the two people who inspired her, Pierre Foldes and Frederique Martz. And it was also very good to catch up more on the news from Linda Weil-Curiel and Diane Walsh.
These occasions offer invaluable opportunities to exchange information and views off-stage as well as in the public domain, and we put every minute of our visit to full use.
These three days around the 2017 GWPF Walk-A-Thon comprised an excellent event for which final thanks must go to Angela Peabody, GWPF’s Founder and Executive Director. We all share with her a strong wish to eradicate FGM and to provide however we are able support for women and girls who have undergone this cruel experience.
Every year that GWPF holds an event such as this, we move a step closer to our ultimate ambition.
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Hilary Burrage sits on the Awards Nominating Committee of Global Woman P.E.A.C.E. Foundation. She is also a 2016 Award Recipient of the Global Woman Awards. She is the author of Female Mutilation and Eradicating Female Genital Mutilation.
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