Don’t look away, Deutschland

Female Genital Mutilation / Cutting: An interview with Terre des Femmes, Germany

By Charlotte Weil (TDF), Nikki van de Veerdonk (MH Hub)and Mariana de la Roche (MH Hub)

This interview is part of the current project titled ‘breaking blades’, a full month program of events to raise awareness on the topic of FGM.C in Berlin, Germany throughout November 2019.

The ‘breaking blades’ events include panel discussions, interviews with guest speakers, film screenings, a photo- and art exhibition and a vulva modeling workshop. A list of the events can be found here.


One health issue that still prevents millions of women worldwide from realizing their full potential is the practice of female genital mutilation / cutting (FGM.C).

FGM.C, can be defined as any and all procedures that involve the practice of partially or totally removing the external female genitalia or causing injury to female genital organs for non-medical reasons. According to Terre des Femmes, worldwide, around 200 million women and girls alive today are affected by FGM.C alive today, and, there are 68 million other girls still at risk of FGM.C between now and 2030.

The health risks of FGM.C detailed by the World Health Organization are extensive. One way that menstrual health is complicated by FCM.C has to do with the face that the vaginal opening may become obstructed, leading to painful menstruation (dysmenorrhea), irregular menses and difficulty in passing menstrual blood, particularly among women with Type III FGM.C Other short- and long term consequences of FGM.C are psychological problems, infections, urinal problems, complications during pregnancy and childbirth and death.

One of the organizations that is highly committed to the topic of FGM.C is Terres des Femmes. Since the founding in 1981, members of Terre des Femmes have been active against FGM.C .

For this article, we corresponded with Charlotte Weil, Policy Specialist Female Genital Mutilation and Project Manager at Terre des Femmes to ask her about the impact of FGM.C in Germany and on a global scale, as well as about the work and commitment of Terre des Femmes towards the topic.

We sought out to understand ‘what are the main challenges related to FGM.C in today’s world, and what is needed to successfully eliminate FGM.C once and for all?


MH Hub: Can you tell us a little bit about what FGM.C is?

TDF: The World Health Organization (WHO) defines Female Genital Mutilation/Cutting, brief FGM.C, as all procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons. This includes the partial as well as the total removal of genital organs or tissue. The WHO further classifies FGM.C into 4 major types:

https://www.rage.com.my/the-hidden-cut/

a) Type 1 — Clitoridectomy: partial or total removal of the clitoris (a small, sensitive part of the female genitals), and in very rare cases, only the prepuce (the fold of skin surrounding the clitoris).

b) Type 2 — Excision: 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).

c) Type 3 — 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. Deinfibulation refers to the practice of cutting open the sealed vaginal opening of a woman who has been infibulated, which is often necessary to allow intercourse or childbirth. Usually, after giving birth, the vaginal opening is sealed together again. This procedure is called Re-infibulation.

d) Type 4: this includes all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.

MHHub: What are the health implications for women who go through FGM.C?

TDF: FGM.C has no health benefits, the consequences of the practice are exclusively negative. Depending on the type of FGM.C and differing form woman to woman, the results may vary from immediate health complications to long-term risks and consequences.

Immediate complications include severe pain, excessive bleeding, infection (e.g. tetanus, HIV), urinary problems, shock, and death. Long-term consequences may include urinary problems (painful urination), vaginal problems, menstrual problems (painful menstruation, difficulty in passing menstrual blood), sexual problems (pain during intercourse, decreased satisfaction), increased risk of childbirth complications (difficult delivery, excessive bleeding, caesarean section, newborn deaths), psychological problems (depression, anxiety, PTSD, etc.)

Photo by Paul Felberbauer on Unsplash

MHHub: Why is TDF Germany working on this particular issue?

TDF: Ever since TERRE DES FEMMES was founded in 1981, female genital mutilation, among other issues, has been a focus point of the organisation’s work.

For us, FGM.C is one of the heaviest forms of violence against women and girls worldwide.

Back then, the topic was not very well known across society, but through TDF it gained public attention in Germany. Apart from that, TDF’s goal has always been to ensure an equal, autonomous and free life for all girls and women around the world. Female genital mutilation fundamentally contradicts this goal which is why TDF fights against it.

MH Hub: How prevalent is FGM.C in Westernized countries such as Germany?

TDF: Regarding overall Europe, the numbers of FGM.C-cases are quite old as the only reliable study conducted on this subject is from 2009. In this study, the European Parliament estimated that within the European union at least 500.000 girls and women are affected, and further 180.000 are at risk of undergoing FGM.C. Since then, the numbers have increased. However, there is still little data among the European countries about the prevalence of FGM.C. Terres de Femmes annually conducts a national statistic on the dark figure of female genital mutilation in Germany.

In 2019, TDF estimates that there are approximately 70.000 affected women and 17.600 girls at risk of being cut in Germany.

Terre des femmes-world map illustrating the prevalence of FGM.C

MH Hub: How does FGM.C appear in the German healthcare system today, both in terms of legislation and practice?

TDF: Since 2013, Female Genital Mutilation is legally regarded as a criminal act under German law (§226a StGB). The practice is seen as a form of bodily harm which can be punished with up to 15 years of imprisonment. If FGM.C leads to death, it is punished under §227 StGB, “bodily harm with fatal consequences”.

If girls and women are suffering under the health consequences of FGM.C, they generally have access to free of charge medical treatments.

The German health care system provides insured persons with the right to receive adequate post-treatment from physicians as well as psychotherapists without any additional payments. However, legal documents explicitly say that this right to post-treatment of FGM.C is only granted to people with a legal health insurance. Asylum seekers and people with a temporary residence permit usually don’t have health insurance and, therefore, are not granted access to such free of charge post-treatment, meaning, they would have to pay for it from their own pockets.

Nevertheless, most people who are affected of FGM.C and suffer from the consequences do not know the opportunities of free medical treatment. In practice, the communities are not well informed about these kinds of services, consequently, they cannot make use of them since they don’t know that this is a possibility.

MH Hub: What measures are in place to prevent women and girls in Germany from having so-called “vacation circumcisions”?

TDF: In order to promote sustainable change and protection of all girls, constant education and sensitisation of the wider society is necessary. Therefore, TDF initiates and coordinates projects across Europe to overcome FGM.C and prevent the continuation of the practice.

But also to raise awareness about the issue among key professionals, institutions and organisations.

For example, our current project “Let’s CHANGE” functions on two different levels. First, the community level: We recruit members of diaspora communities where FGM.C is practised and train them to become multipliers of their own communities, so-called CHANGE Agents. As CHANGE Agents they organise community events, host group discussions or hold presentations about the issue and thereby initiate a behaviour change. They are also in direct contact with affected families and girls at risk, which means that they can give advice on support services and contacts for counselling.

Photo: © TERRE DES FEMMES

The second level, however, is the level of key professionals where former CHANGE Agents from previous projects receive a deeper training in order to educate social workers, teachers or even police officers on FGM.C. These professionals learn how to talk about the issue when encountering, what to do in a moment of suspicion and whom to contact. The exchange of knowledge among key personnel who may come in contact with FGM.C is also crucial in order to protect girls and prevent circumcisions during holidays or abroad. It also creates a competent network of relevant professionals who can share information and support each other.

Furthermore, Germany has a new law according to which the passports of parents may be withdrawn to prevent these so-called “vacation circumcisions”. If a school teacher or a doctor has reasonable assumptions that a girl might be cut in the holidays, he or she can contact a counselling centre or the police to inform them. The local authorities would then take the parents’ passport, so that they cannot leave the country. But such laws are surely not enough. We need sensitisation and change of behaviour across all spheres and groups of society. Only then, can we finally overcome FGM.C.

MH Hub: What is reconstruction surgery?

TDF: Reconstruction surgery basically describes an operative procedure which attempts to restore the female genital organs to the extent that it feels “normal” again for the affected girls and women. The latter, the feeling of normality, is particularly important to those affected by FGM.C. Certainly, nothing that has been removed can be restored completely. However, the anatomical structure of the clitoris allows that the circumcised women can regain sensitivity since a large part of the clitoris is located beneath skin level and can be quite easily exposed when removing the scar tissue. In this way, the clitoris may reappear at the vaginal opening and can be “reactivated”, so that to a certain extent sexual sensitivity might be possible again. Still, affected people need to be adequately and fully informed about their options for reconstruction. Each step towards a surgical intervention must be discussed with the woman herself and she must explicitly decide in favour of such an intervention. Therefore, extensive counselling is necessary in advance.

Germany only has a few doctors who practise plastic reconstruction surgery of the female genitalia. Terre des Femmes cooperates with Dr. med. Dan mon O’Dey, a specialist for plastic and aesthetic surgery at the Luisenhospital in Aachen. He developed a special method according to which the outer genital organs can be largely reconstructed. A detailed explanation of his surgery method can be found on the website of stop mutilation e.V. (German) or in his recently published book “Vulvar Reconstruction Following Female Genital Mutilation/Cutting (FGM.C) and other Acquired Deformities”. The special thing about Dr. O’Dey’s technique is that it not only reconstructs the vulva functionally, but also aesthetically. In this way, his reconstruction surgery establishes a balance between the woman’s physical self image and her psychological perception, and thereby, contributes to the bodily integrity of affected women.

MH Hub: What does a woman who has suffered from FGM.C need to do to access this process in Germany?

TDF: If a woman is considering reconstructive surgery, she can just come to the general office hours of Dr. O’Dey discuss with him the various possibilities of operation. Alternatively, she may also go to the Desert Flower Center in Berlin to consult some information. Every talk happens in a confidential and sensitive atmosphere and is hosted by medical experts who are specialised on FGM.C.

MH Hub: Is reconstruction surgery covered by German health insurance?

TDF: Yes, it is. In 2013, FGM.C-related treatments have been included in the medical services of the national insurances. All four type of female genital mutilation are therefore covered by the German health care system. This also includes reconstructive surgeries.

MH Hub: How can we address the threat of FGM.C at the global level?

TDF: We need global sensitisation campaigns to overcome FGM.C. People, affected or not, need to know the motifs of the practice, the health consequences and what it means for women’s and girls’ human rights. Similarly, there should be adequate professional support for affected women and girls. Doctors, psychologists, social workers, counsellors, teachers etc. should be aware of the risk of FGM.C in their field of work and they should be ready to act properly when necessary. Key professionals who encounter FGM.C in their work should receive profound trainings and information material on how to behave, so that in case, women and girls get the support they need and are protected.

MH Hub: What are the main challenges to achieving this goal, locally in Germany as well as globally?

TDF: It is particularly important to note that female genital mutilation is a social norm in communities where it is practised. Many people perceive it as a given part of their community that has existed before them and continues to exist after they pass. Moreover, if you live in a community where all of the women and girls you know are circumcised, then, you will think that this is how it has to be and that circumcised genitals are a normal thing. That is also the reason why the practice is rarely questioned or criticised by affected communities. However, if a person comes into a country where FGM.C is not the norm and maybe even meets women who are not circumcised, they will start to question the practice and its purpose.

Still, living in Germany is no guarantee that future generations of girls won’t be cut since most families experience strong pressure from their communities to continue the practice. Grandparents or uncles and aunts pressure them to circumcise their daughters. Not doing so, would result in social stigmatisation, exclusion or even discrimination from the own family members.

This is why, sensitisation work is crucial.

MH Hub: What is needed to successfully eliminate FGM.C once and for all?

TDF: It is further important that alongside campaigns, international projects and education impactful laws are in place that prohibit FGM.C and sanction the practising of it. Only if both things go hand in hand, female genital mutilation can be overcome for the long term.


About

The Menstrual Health Hub (MH Hub) sees menstrual health as the entry point to being able to meaningfully understand and address female health across the life cycle.

In 2019, the MH Hub began supporting work of Antje Pohsegger, an artist who has committed her work to exposing the experiences of women affected by FGM.C and making their stories accessible to people who live here in the German-speaking world. Together, Antje, Terre des Femmes and the MH Hub have organized ‘breaking blades’, a full month program of events throughout the month of November to raise awareness on the topic of FGM.C.

The ‘breaking blades’ events include panel discussions, interviews with guest speakers, film screenings, a photo- and art exhibition and a vulva modeling workshop. A list of the events can be found here:

The objective of this grassroots project is to generate more awareness about FGM.C. We hope that you join us in one or more of the ‘breaking blades’ events in November in Berlin!

For more information, please reach out to mariana@mhhub.org.

Menstrual Health Hub

Written by

A global female health impact consultancy working with the public & the private sector to strengthen collective impact & increase innovation around the globe.

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