Pursuing an end to FGM

Ms Ifrah Ahmed is one of the world’s foremost campaigners against female genital mutilation, having started her activism as a teenager in Ireland. Catherine Reilly spoke to Ms Ahmed and Irish healthcare and policy professionals about a worldwide problem that is hitting home

In Mogadishu’s corridors of power, Ms Ifrah Ahmed became known as the “Irish woman”. As an advisor to Somalia’s federal government, the Somali-Irish citizen petitioned ministers to “break the silence” on female genital mutilation (FGM), which is highly prevalent in the east African country. Worldwide, over 200 million women and girls are survivors of FGM, Ms Ahmed among them.

FGM comprises all procedures involving partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons. It is usually carried out by local women using basic items. It has no health benefits and many negative immediate and long-term consequences, according to the World Health Organisation (WHO).

The commonly-cited motivations for the practice are social traditions, control over female sexuality, marriageability and religion, although no faith obliges FGM. Somalia, at 98 per cent, leads the countries with the highest prevalence among girls and women aged 15-to-49. Moreover, the most brutal form of FGM — type 3, or infibulation — is the most common in Somalia (see panel below). There is no legislation prohibiting FGM in Somalia and the practice is so deep-rooted that activists face an uphill struggle to encourage change.

But this has not dissuaded Ms Ahmed. When it comes to winning friends and influencing people, she has written the textbook. “Every minister has two or three police guards at the door, and the minister can hear me fighting with them, because they don’t allow anybody to enter to him,” Ms Ahmed tells the <em><strong>Medical Independent (MI)</strong></em> of her time as a gender and human rights advisor. “For me, always when I go, I say to the police guards ‘hey listen, this government kick out every minister after three months, so he will disappear soon, so let me go and see him’. The minister would hear me and say, ‘hey, let her in’… ”

<h3>Shunned</h3>

In 2006, Ms Ahmed arrived in Ireland as a lone teenage asylum-seeker; she was granted refugee status and later citizenship. In 2008, still aged in her teens, she told the multicultural newspaper <em>Metro Éirean</em>n that Somali women were coming “under pressure” to send their young Irish raised daughters to Somalia for FGM. Thereafter, she was shunned and threatened by elements of her community. Her motivation was born from the pain and trauma of peers, who at times endured ignorance and shock in healthcare settings.

From her small flat in Drumcondra, Dublin, she co-ordinated a growing band of supporters, bringing the worlds of fashion and politics together for awareness events. Her efforts were influential in ensuring the introduction in 2012 of legislation specifically outlawing FGM and the act of removing girls or women from the State, or attempting to remove them, for FGM. Her work was the focus of an RTÉ <em>Would You Believe</em> documentary in 2013. She is now an independent activist with the Ifrah Foundation, an Irish-registered charity that she founded. Her vision is that a campaign focused on FGM eradication will acquire a profile similar to that surrounding HIV/AIDS.

There is “a real steely determination behind what she is doing”, remarks Prof Chris Fitzpatrick, Consultant Obstetrician and Gynaecologist at the Coombe Women and Infants Hospital, Dublin, Clinical Professor at the School of Medicine, University College Dublin and an advisor to the Ifrah Foundation. “I think the momentum that has been generated by the #MeToo campaign has added extra impetus in relation to the significance of FGM, because it puts it into a context of violation of women’s rights. The local connection where somebody came here as an asylum-seeker to actually get to a position where you can found a foundation and advocate at many different levels is a phenomenal example of female empowerment.”

It is estimated that 5,795 women and girls living in Ireland have undergone FGM in their native countries, according to African and migrant women’s network Akidwa. In 2015, an EU-funded report found that between 1-to-11 per cent of the almost 14,600 girls under the age of 18 in Ireland, whose parents originate from practising countries, could be at risk of FGM.

A major risk factor is the girl being brought to the parental country of origin, where family members may arrange for the practice to take place, stated the report. In focus groups held as part of this report, “anecdotal cases” emerged of girls being taken from Ireland to “countries of origin” by their parents for FGM. There were no specific scenarios of it being performed in Ireland. “Participants had met or heard of parents in the direct provision system who wanted to cut their daughters, but this appeared to be rare. According to the groups, if parents or families really wanted to practise FGM, they would travel to their country of origin and possibly not return to Ireland.”

The issue of girls potentially being sent abroad remains a concern, according to Ms Alwiye Xuseyn, Manager at Akidwa. In discussions with some immigrant communities, “it will come up that, yes, the practice will still continue because it is deep-rooted,” says Ms Xuseyn, “but we don’t have the proof”. On 1 February, a man and woman were sent forward for trial accused of the genital mutilation of their daughter in Dublin. The couple cannot be named for legal reasons and have not indicated how they will plead. A Garda spokesperson told <em><strong>MI </strong></em>that it has developed a crime classification code for FGM. However, this offence was only created in the coding system last year and no figures will be available until the end of 2018, they said.

“The Garda National Protective Services Bureau are currently engaged in training and awareness education programmes and deliver training to front-line operational personnel twice yearly. The bureau also engages with a wide range of agencies and law enforcement in presenting on the crime of FGM at national seminars,” added the spokesperson. Tusla said it does not have a specific category for FGM in respect of referral data.

<h3>‘No basis in Islam’</h3>

While FGM affects people of different religions, some members of Muslim communities argue an Islamic context to the practice. Shaykh Umar Al-Qadri, a progressive Imam in Dublin, strongly disputes an Islamic basis.

“In my view and the view of most Muslims, this is a cultural practice; it has no basis in Islam and no basis in Islamic law, and it is of course harmful and should not be practised. It should be discouraged. There is a minority view among some Muslims that there are, for example, some narrations that would not make it an obligation but would recommend such a practice, however these narrations have been proven to be unreliable, unauthentic, so therefore the majority of opinion is that it is a practice that has nothing to do with Islam.

“We do not find it in the time of the Prophet Muhammad, we do not find authentic sources, and also anything that is harmful for the body, anything that is harmful for one’s physical body and psychologically harmful, will always become harmful in Islam and always be discouraged because we in Islam are not allowed torture or physically harm ourselves; it is very much discouraged.” In 14 years here, he has not had an enquiry about undertaking FGM.

“We have had discussions [about the issue]; there were people from Somalia and Sudan, some of them that were sharing their views during the discussions, but again it was made clear to them and they also understood that it is a cultural thing, which is perceived by some as religious, but it isn’t. “They weren’t enquiring for their children but during discussions on this issue, they brought up that it is practised among their communities, among some members of the communities back home. [We were] discussing that there was no religious backing of it and they agreed on it.”

However, Dr Ali Selim (PhD), a senior figure in the Islamic Cultural Centre, Clonskeagh, has a different view. Some years ago, he put on record that the Centre opposed the proposed ban under the Criminal Justice FGM Act. In comments to<em> Metro Éireann</em> in 2010, he contended that the Centre was against FGM but not “female circumcision” (these terms are often used interchangeably). He referred to types of cutting to the female genitalia that are illegal under the legislation that commenced in 2012 and are commonly categorised within the definition of FGM.

Contacted by <em><strong>MI</strong></em> for the latest position, Dr Selim answered: “I believe you know my stand in this regard. I adhere to it. It cannot be banned but reasonably practised.” He believes a hadith (saying of the Prophet Muhammad) provides an Islamic context to “female circumcision”. “Female circumcision is a matter that should be determined by a medical doctor. If the doctor thinks there is a need for it, then do it and if otherwise, then otherwise. If it is done, then it should be done carefully and safely and should be limited to the amount needed,” Dr Selim informed MI.

Dr Selim said that “female circumcision is a matter that should not be banned nor haphazardly practised… it has to be sanctioned by a medical doctor who can recognise the need of that”. He was unable to identify any specific alleged medical needs (“sometimes you could have an abnormal part in your body and it will have to be treated”, he said). When asked if the alleged medical issues were a reference to matters around promiscuity, he said “no”.

Informed of some of Dr Selim’s comments, Prof Fitzpatrick stated: “Female genital mutilation is a crime against young girls and women. There are no health benefits — just misery, suffering and ill-health for millions. It is a criminal offence for a doctor to perform FGM. There is no such thing as ‘reasonable practice’ or ‘limited excision’.

“Phumzile Mlambo-Ngcuka, the Executive Director of UN Women, sums up the horror of this practice: ‘The cutting and sewing of a young girl’s private parts so that she is substantially damaged for the rest of her life, has no sensation during sex except probably pain, and may face further damage when she gives birth, is an obvious and horrifying violation of that child’s rights.’

“There are many, many Muslims who oppose this barbaric practice and there is, I believe, a moral imperative for Islamic religious leaders, as well as all politicians and other religious and secular leaders in countries where FGM is practised, to come out strongly and unequivocally in opposition to FGM and to support its total abolition.”

<h3>Dublin clinic</h3>

The extent of FGM in Ireland and its perpetration on Irish citizen girls is difficult to gauge. However, some women who suffered the practice in their native countries are presenting to health services. In mid-2014, the first specialist health clinic on FGM was opened by the Irish Family Planning Association (IFPA) at Cathal Brugha Street, Dublin. Policy Officer at the IFPA, Ms Alison Spillane, says the clinic has had less than 50 clients to date. The number of clients is increasing year-on-year, however, and most attend on multiple occasions. The clinic provides free medical and psychological services, including interpreting support, if required. In 2017, it received HSE funding of €38,000, which “covers the clinical services and the outreach activities to both affected communities and front-line service providers”.

The IFPA raises awareness of the clinic during outreach information meetings at direct provision asylum-seeker centres. A clinical pathway has been established into Dublin’s Rotunda Hospital. In 2016, half of new clients had an onward referral to the Rotunda for consideration of deinfibulation.

“Because the client numbers are so small, the gynaecologist we work with in the Rotunda [Dr Maeve Eogan] is able to integrate those into her own caseload. I guess down the line, assuming the client numbers increase, we might need to look at that pathway again, and maybe develop a network of gynaecologists around the country who are able to provide the service,” stated Ms Spillane.

Dr Eogan, Consultant Obstetrician and Gynaecologist, says the IFPA clinic is a “holistic” service that provides a “huge benefit” for these women. The hospital sees women referred for sequelae of FGM. Around five-to-six women per year are referred for consideration of deinfibulation, which is a straightforward procedure. Surgical care and knowledge of FGM are part of basic and higher specialist training in obstetrics and gynaecology, confirms Dr Eogan.

It is underlined to trainees that women may not disclose a history of FGM due to fear, trauma, embarrassment or it may not be foremost in their mind during an antenatal visit. Affected women may present late to maternity services, “and that is why training is so important”, says Dr Eogan. On the hospital’s electronic health record, FGM can be noted “in the area where we document vaginal exam during labour”. This will relate to a minority of patients but is an important acknowledgment of such presentations, she adds.

Asked if patients ever ask for re-infibulation, which refers to the re-suturing (usually after childbirth) of the incised scar tissue and is illegal under the Criminal Justice FGM Act, Dr Eogan says: “No, that is not something I have come across. But whenever we are talking to trainees in this regard, we also ensure that we emphasise that repair of episiotomy or perineal tears still needs to be done in the usual fashion after childbirth; whatever suturing is required to achieve haemostasis is entirely appropriate.”

Currently, specialist services on FGM are Dublin-centric, an issue raised by the organisation Action Aid. It has called for additional resources to ensure the provision of medical treatment and psychosexual therapy for survivors of FGM in the Cork region. Prof Fitzpatrick says “there is significant awareness there [in healthcare]. I think there needs to be more awareness, and I think there needs to be ease of access into services. “My experience, and the numbers are very small, is that women with FGM have actually been identified early in the [maternity] services, but are often not identified until they actually attend a maternity service, so it is oftentimes the first point of contact.”

Akidwa has produced booklets on FGM for healthcare professionals and teachers; a guide for gardaí is under development.

Ms Xuseyn says Akidwa “would like to see” more State support for its work “other than the small bit we are receiving, because there’s a lot that needs to be done”. In 2017, the organisation received €70,000 from the HSE for its work on FGM. Akidwa wants to work more closely with people from FGM-practising countries to provide education on the health consequences of FGM and on the Criminal Justice FGM Act. It also wants to further engage with service providers to better equip them in supporting women affected by FGM, according to Ms Xuseyn. “We are doing all of that but in a very struggling situation because of lack of funding.”

<h3>Security risk</h3>

Over the last decade, Ms Ahmed was the principal driver of FGM awareness in Ireland. In 2013, she went back to Somalia on a short visit, which was her first since leaving the conflict-torn country. “I remember meeting with [a security advisor] and him explaining to me that anything can happen — you can be kidnapped, you can be killed, you can be recognised because you’ve been in the media,” she tells MI.

“But I felt, if I can do it in Ireland, why can I not do it in Somalia because I felt great when the FGM Bill passed in Ireland and I felt at least Ireland is a country with legislation, a country that is better than Somalia [in this respect] and where those who practise FGM can be facing the consequence of imprisonment. So it was not an easy decision to go back but I really wanted to make that journey and see how it is like as a grown woman to go back to my own country, because I came here when I was knowing nothing but I learned so much. I felt I had the power to speak to people, to influence, and knew how to communicate.”

She kept a low profile while meeting with family and visiting camps for internally-displaced people (IDP) in Somalia. She encountered three girls at an IDP camp at immediate risk of FGM and paid their families to not go through with it. “They started talking… they said ‘okay, we are not going to cut them, we are going to do sunna’… Sunna is that they cut it a little bit and make it bleed. I said ‘no, you take the 100 dollars and you leave the girls forever’.” The families took the money and swore on the Koran that the girls would not be touched.

On return to Ireland, she was depressed thinking of the poverty, hunger and insecurity she had witnessed. “But again, I said, my depression, me being sad about how people are living, I should start thinking positive; what can I do? I felt, you know what, if I went back to Somalia and started breaking the silence, that will help. But I meet with everyone, I see their life, the killing, the bombing, everything, I say okay, the country where there is a bomb every day and every single day people are killed, how would I make a change and how would I survive myself being in that situation? Then I said, ‘you know what, I am going back’.”

In 2014, she got the opportunity to advise the country’s Minister for Women and Human Rights Khadija Mohamed Dirie. In 2016, she persuaded Prime Minister Omar Abdirashid Ali Sharmarke to sign a petition calling for a ban on FGM in Somalia and worked as an advisor under his office. She saw plenty of heartache. “I visited hospitals where I find that a lot of women have gone through fistula… I meet with women who cannot hold their urine and they have to be in hospital 24/7 with a tube, because the first child they gave birth to, it was very hard, then they have a fistula, now they have lost all their life. Where is the health?”

One girl she met, Hawa, faced renal failure arising from the consequences of FGM. Ms Ahmed enlisted the help of authorities and medics in a bid to save Hawa. Sadly, she did not survive.

FGM is entrenched in Somalia, but the country has many other problems. It is still emerging from conflict and routinely faces attacks from Islamists, notably al-Shabaab. This constitutes a very volatile climate for all human rights activists.

Currently, Ms Ahmed is focusing on her work as an activist through the Ifrah Foundation. It has been awarded a grant from Amplify Change to implement a pilot FGM eradication programme in the Gedo region of Somalia. The programme will be undertaken in collaboration with Trocaire and the Global Media Campaign to End FGM, founded by The Guardian.

The Ifrah Foundation has developed a National Action Plan study for Somalia, which targets eradication of FGM by 2030. The aim is to work in partnership with government and global stakeholders with a collective interest to eradicate FGM in Somalia using a sustained programme for change and collaborating with civil society and communities to achieve permanent change. In December 2017, the Ifrah Foundation worked with the Global Media Campaign to End FGM, local government and other partners to deliver training on ending the practice to media and religious leaders in Puntland. The buy-in of religious leaders will be key in ensuring legislation banning FGM can be instigated and respected, explains Ms Ahmed.

Further developments are afoot. A film titled<em> A Girl From Mogadishu,</em> directed by Ms Mary McGuckian, will tell Ms Ahmed’s story. The project received funding from the Irish Film Board and will film scenes in Dublin shortly. The aim is to raise awareness of FGM and impact societies around the world, says Ms Ahmed.

The ‘Irish woman’ will surely see to it.

<span style=”font-size: medium;”><strong>Types of FGM categorised by WHO</strong></span>

Female genital mutilation is classified into four major types.

Type 1: Often referred to as clitoridectomy, this is the partial or total removal of the clitoris, and in very rare cases, only the prepuce (the fold of skin surrounding the clitoris).

Type 2: Often referred to as excision, this is the partial or total removal of the clitoris and the labia minora (the inner folds of the vulva), with or without excision of the labia majora (the outer folds of skin of the vulva).

Type 3: Often referred to as infibulation, this is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora or labia majora, sometimes through stitching, with or without removal of the clitoris (clitoridectomy).

Type 4: This includes all other harmful procedures to the female genitalia for non-medical purposes, eg, pricking, piercing, incising, scraping and cauterising the genital area.

Source: World Health Organisation