Is female circumcision really a risk factor for HIV?

Opponents of female circumcision make the case that it is a risk factor for contracting HIV. But is it? In fact, at least some research draws the opposite conclusion. But is that a reason to tolerate it? The answer is absolutely not.

It is hard to quibble with any arguments that cast female circumcision in the worst possible light. Yet it is also hard to take statements that do not acknowledge the parallels between female and male circumcision [pdf]. The article below the fold asserts some unfortunate claims that aren't likely to help the cause to wipe out the practice of either mutilation.

Full critique in red below the fold.

The link between female genital mutilation and HIV transmission

Researchers and activists are linking the feminization of HIV-AIDS in sub-Saharan Africa with another major health affliction for women in the region: female genital mutilation.

Sporadic research data over the past 10 years has correlated dirty cutting equipment, hemorrhages requiring blood transfusions, and injurious sexual intercourse causing vaginal tearing and lesions with rising rates of HIV transmission among women in countries where female genital mutilation (FGM) is still widely practiced. [And the correlation between rising HIV prevalence and dirty cutting equipment has been noted where male circumcision is practiced as well. And in Africa, the risks related to MRSA are unknown.]

Because FGM is coupled with the loss of blood and use is often made of one instrument for a number of operations, the risk of HIV-AIDS transmission is increased by the practice," the New York-based United Nations Population Fund says on its website. "Also, due to damage to the female sexual organs, sexual intercourse can result in lacerations of tissues, which greatly increases risk of transmission. The same is true for childbirth and subsequent loss of blood."

Other organizations, such as the London-based International Community of Women Living With HIV-AIDS and the Washington-based Global Health Council, make similar assertions on the immediate risks of HIV transmission and anti-FGM activists in the region express confidence in the link.

A representative from the Network against Female Genital Mutilation in Moshi believes there is a link between FGM and HIV transmission, and a delegate from the National Union of Djiboutian Women — who asked to remain anonymous — says she believes FGM is the single largest contributing factor to HIV infection in that country, with risks that are immediate, as well as long-term.

Meanwhile, a cross-section of data drawn from a 2006 United Nations report on the global AIDS epidemic, for instance, shows that in several countries in Africa where FGM is common—including Somalia, Sudan, Tanzania and Djibouti—between 55 and 60 per cent of HIV-infected individuals are female. [This rate is not dissimilar to areas where female circumcision is uncommon.]

Increasing evidence

The FGM-HIV link is currently more of a murmur than a rumble among activists, watch-dog groups and major health authorities. While scientific evidence is sparse—though steadily mounting—to link FGM to HIV transmission there is a definite connection, according to Human Rights Watch.

"Although few clinical studies have been conducted, it is clear that at least some forms of FGM increase the HIV transmission risk faced by women and girls, both in that unsterile instruments may be used in the cutting and because some FGM is associated with chronic genital injury and tearing, ulceration and delayed healing of injuries, all of which may increase HIV risk," the New York human rights group concluded in a December 2003 report.

The Geneva-based World Health Organization also acknowledges that FGM may be linked to a higher risk of HIV infection for women.

"More recently, concern has arisen about possible transmission of HIV (from FGM), due to the use of one instrument in multiple operations, but this has not been the subject of detailed research," states the World Health Organization (WHO) on their Web site. [Point worth repeating, obviously, but one equally applicable to the male version.]

Marianne Sarkis, director of the Female Genital Cutting Education and Networking Project (www. fgmnetwork.org), agrees with other experts and activists and explains on her website how FGM can lead to HIV infection.

“Female genital cutting (FGC) has long-term physiological, sexual and psychological effects,” Sarkis explains. “The unsanitary environment under which FGC takes place results in infections of the genital and surrounding areas, and often results in the transmission of the HIV virus, which can cause AIDS.” [These problems have an obvious solution. Medicalization. Repeating this mantra that it is unsanitary does not help the effort to stop the practice. The emphasis should be that it is often forced, botched, and has psychological consequences -- the same psychological consequences that males can suffer.]

FGM common in parts of Tanzania

Though outlawed in most countries, FGM continues to be practiced in 28 African nations, as well as parts of the Middle East and Asia, according to the World Health Organization, the United Nations health arm.

WHO findings indicate that between 5 per cent and 97 per cent of women in the regions in which FGM is performed have undergone the procedure. Worldwide, more than 100 million girls have undergone FGM, with 3 million undergoing it  each year.

Prevalence varies across Tanzania, but in parts of the country, between 18 and 100 percent of girls are subjected to female genital mutilation.

“According to recently released data on FGM prevalence in Tanzania by the Tanzania Demographic survey in Kilimanjaro region, the prevalence rate has dropped to 25 per cent (in 2005-06) against 15 per cent nationally,” says Michael Reuben, a program officer with the Network against Female Genital Mutilation (NAFGEM), based in Moshi, Tanzania. “The previous static — dating from 1996 — indicated the prevalence in Kilimanjaro was 37 per cent, against 18 per cent for the rest of the country.”

Reuben says FGM is considered by some cultures in the region as a rite of passage into womanhood, and a prerequisite for marriage, bearing children and acceptance into the community. It also increases the bride price in some East African tribes, including the Maasai. The price, typically paid in cattle in Maasai communities, is the offering made by the husband-to-be to the bride's family. [It is a problem of culture.]

“FGM is very common in some regions of Tanzania, especially among the Maasai communities inhabiting the northern zones of Tanzania, including Arusha and Kilimanjaro,” Reuben points out. “The practice is based on love and a desire to protect. It is viewed as a cultural practice with deep social significance for females and a necessary rite of passage into womanhood.” [Identical reasons male circumcision is often forced on infants and children in the United States.]

Reuben notes that FGM is also performed in some cultures to promote tribal cohesion as girls with intact genitalia are thought to contradict the values of the community. [Same in the United States viz male children.]

"FGM enhances male sexuality [patently false and arguably anti-male], while preventing promiscuity and preserving virginity [likely equally false]," says Reuben. "It minimizes sexual desire and feelings on the part of women, and thereby discourages prostitution. [Utterly absurd as prostitution is rarely practiced for the sexual thrill of the woman. Prostitution is generally an economically forced activity.] It is also performed because the clitoris is viewed as unhealthy." [Like the foreskin in the United States.]

He asserts that FGM plays a role in the transmission of HIV.

“One of the health effects of FGM is the transmission of HIV,” Reuben says. “This is due to the fact that the circumcisers, known as ngariba in Swahili, use unsterilized tools, such as knives and razor blades, for performing FGM. These tools are used on more than one person at a time. It is greatly believed that the tools contribute to the transmission of the virus, although reliable data is not yet widely available.” [Yes, we got that part several paragraphs back.]

NAFGEM’s assertions are supported by research dating back nearly a decade. In a 1999 article published in AIDS Patient Care and STDs, Margaret Brady, a nurse and clinical researcher, found that the same cutting instruments were used on at least a dozen girls.

“One recent article, which was presented at the International Conference on AIDS 1998, was a study performed on 7,350 young girls less than 16 years old in Dar es Salaam,” Brady writes. “It was revealed that 97 per cent of the time, the same equipment could be used on 15-20 girls. The conclusion of the study was that the use of the same equipment facilitated HIV/AIDS/STD transmission.”

Brady explains that FGM also poses several long-term risks that may contribute to HIV infection.

“A study performed in Nairobi indicated that FGM predisposes women to HIV infection in many ways, including increased need for blood transfusions due to hemorrhage, either when the procedure is performed, at childbirth, or as a result of vaginal tearing during defibulation (vaginal opening) and intercourse,”  she explains. [In Africa, the likelier outcome is death. Not HIV infection from blood transfusions.]

Women who have undergone type III FGM (also known as infibulation) have only two small openings large enough to allow the passage of urine and menstrual blood. This makes intercourse difficult and painful, often causing repeated tissue damage, lesions and bleeding. Brady says this can actually change the chemistry of the vaginal walls, which can facilitate the transmission of HIV into the bloodstream.

Outlawed Practice Continues

Of the three major types of FGM, the most extreme is type III, also called infibulation or Pharaonic circumcision, in which the clitoris and labia are removed and the vaginal opening is stitched shut, leaving only a small space for the passage of urine and menstrual blood.

Type III is rare in most countries, according to the Human Rights Watch report, which found that 15 per cent of women and girls who had undergone FGM had suffered infibulation.

But the practice  is common in Somalia, Djibouti and Sudan. In these countries more than 80 per cent of FGM cases involved infibulation.

Djibouti has an HIV prevalence rate of approximately 3 per cent (of an estimated population of 793,000), according to a 2006 report from UNAIDS, the Joint United Nations Program on HIV-AIDS. Sixty per cent of adults  living with HIV-AIDS (aged 15 and up) are female and around 98 per cent of females in the country are subjected to some form of FGM. [While I would like to believe this makes the argument against the practice, the numbers really don't demonstrate anything other than correlation and even that isn't clear.]

The National Union of Djiboutian Women, a national women's rights group based in Djibouti  City, lobbied the government to have FGM abolished and in 1994  infibulation was criminalized. Despite the law, it continues, primarily in outlying and rural regions.

"Even well-educated citizens practice FGM," says the representative from the National Union. "It's a traditional practice and a traditional belief. It's deeper than the law." [Just like male circumcision in the United States. Glass houses and stones for us Americans.]

mkkeown@gmail.com

Reference

Keown, Mary Katherine. The link between female genital mutilation and HIV transmission. The Arusha Times (Tanzania). November 17-23, 2007.

http://www.arushatimes.co.tz/society_5.htm

 

Comments

[J]

Interesting. I saw this article too and one thing that struck me was that there was no mention of the Stallings study. I mean with the crisis we are facing in Africa when you see:
"In the final logistic model, circumcision remained highly significant [OR=0.60; 95% CI 0.41,0.88] while adjusted for region, household wealth, age, lifetime partners, union status, and recent ulcer."

Fortunately, a 2002 study found: Circumcised women experience sexual arousal and orgasm as frequently as uncircumcised women.

So with HIV protection and no apparent damage to their ability to be sexually aroused or have orgasms, don't you think we should investigate further? Correct me if I am wrong but to date there has been no promotion, no follow up, and certainly no media touting this as a bold new treatment option. No, certainly not. That would be inhumane the study considers it a "conundrum" but when it comes to males well the story is: "I always knew that foreskin was dirty."

Now I do have to concede that there are implementations of Female Genital Mutilation that are worse than Male Genital Mutilation (as MGM is practiced in the West) but most are parallel and I am often befuddled at the stunning double standard that exists in the west when discussing FGM Vs. MGM. In the former case it is forbidden no matter how trivially, aseptically, or ritually it is performed. While in the later case there is no protection. It's one of those things that I have difficulty wrapping my mind around that people can't see how similar they are. It is clearly a situation of the cultural blinders that we wear here in the West but in almost all case nobody realizes it. Fortunately, to help re-enforce the point, there was an article
about FGM in Egypt which illustrates this perfectly.

From the article:
... and an unmutilated girl will be regarded by the community as "impure", facing many taboos and social rejection. The dishonored family could not marry her without the "rite of passage" from childhood to adulthood (so that she makes "good marriage material")....

Just replace girl with boy and mutilated with circumcised and we get the excuse many parents make to mutilate their sons:

..., and an uncircumcised boy will be regarded by the community as "impure", facing many taboos and social rejection....

From the article:
"About 75 % of the circumcised Egyptian girls are cut by medical personnel (doctors and nurses) who receive $8.85-88.50 for each operation. In Egypt, girls die due to a wrong dose of anesthesia or from hemorrhage."

In the West:
... circumcised boys are cut by medical personnel (doctors and nurses) who receive $200 - $300 for each operation. In the US boys die due to shock, hemorrhage, infection, ect.... London 2007, Cleveland 1998, Ontario 2007

Are there more? Of course there are. The interesting thing is when a boy dies or is maimed it's a terrible tragedy but it is not the procedure. No one questions the procedure but when a girl in Egypt dies it is a terrible tragedy and the impetus to place pressure to ban the procedure no matter how culturally ingrained it may be. Why don't boys get the same consideration?

From the article:
"There is not one person here not circumcised, and it will continue", a 16-year-old secondary school Egyptian girl student commented.

Don't really have to fix this sentence, just replace Egyptian with American. It would work well talking about FGM in Egypt or MGM in the US. Finally, though not in this article, those who practice FGM would tell you how much cleaner a circumcised women is.

If people would just take some time to research and think about it they would realize that reasons Africans mutilate their daughters mirror's their own desires to mutilate their sons. I think, as you pointed out Dave, that Robert Darby's and Steven Svoboda's (2007)

A Rose by Any Other Name? Rethinking the Similarities and Differences between Male and Female Genital Cutting. described this phenomena well. It is time these similarities are acknowledged and we give boys the same protection and consideration as we give girls.

Sorry for the double post the links were messed up; here it is with the links working. Dave feel free to delete the first version.

Ed. Note: No problem. Thanks for this thorough examination of this topic.

[J]

Thanks for the correction Dave. A thorough examination of the cultural parallels is easy it's like shooting fish in a barrel. People just don't seem to realize that it's the same dance just a different tune.

I also just noticed the link to the main article I referenced was wrong so here it is again for the readers: Egypt FGM article

If you can fix the original post that would be great there was just an 'o' at the end of the '.shtml' that shouldn't be there. Keep up the good work.

[Joe in CA]

Now I do have to concede that there are implementations of Female Genital Mutilation that are worse than Male Genital Mutilation (as MGM is practiced in the West) but most are parallel and I am often befuddled at the stunning double standard that exists in the west when discussing FGM Vs. MGM.

And I must concede that even though FGM might actually be "worse," the principle of taking a non-concenting individual and forcefully cutting up his/her genitals against his/her will is precisely the same.

People like to take the "worse" excuse to set what they do in their own country apart. Since FGM is "worse," MGM is OK.

But this reasoning works no-where else. Murder is worse than rape. So is rape OK? Infibulation is the worst kind of FGM. So are all other forms OK?

I have written about this in blog at MySpace, as well as created a visual comparison exercise that I hope will make people see my point.

Here are links to my first and second blogs.

"Don't You DARE Compare!"

"FGM is MUCH Worse..."

Here is a link to my visual comparison exercise.

"Visual Comparison Exercise"

[RogerRabbit]

Yeah, there's definitely a double standard going on here ...

Good work!