Special Needs of Ritually Circumcised Women Patients

Accepted May 1990

Fatma and her family returned to Sudan, in sub-Saharan Africa, after a six-year stay in the United States. While in the United States, Fahtma's husband, now a high official in one of the Sudanese ministries, studied at a mid-western university and created a doctoral degree. The family now lives in El Fasher, a governmental center in Western Sudan. Fahtma has three sons and a daughter. She explains what it was like for here to give birth in the United States:

They asked me at the hospital if they could take pictures. They had never seen anything like it before. I said, Sure, why not? It didn't make any difference to me. They weren't going to photograph my face, after all. So they took pictures of the whole birth.

It was very funny. A young nurse came in with a tray, carrying a razor, soap and a bowl of water. She was going to shave me. She pulled down the covers and asked me to pull up my hospital gown. When she looked at the place she was going to shave, she screamed and dropped the tray. The whole bed was full of water, and they had to change the sheets and blankets and give me a fresh gown. The nurse was so upset. She kept apologizing. They must have asked her why she screamed like that, and she must have told them, because they all looked so stricken and embarrassed, and I could tell that they all wanted to see it, but they were afraid to ask because they were afraid that they would hurt my feelings. They all knew me, because I had been working at the hospital as a practical nurse.

Female circumcision is still widely practiced in a large part of Africa north of the equator. The number of affected women has been estimated to be more than 80 million.¹ The procedures involved in female circumcision are extensively damaging medically, causing mutilation to healthy external female genitalia.

Ritual circumcision, at it is performed in Africa is intended to sexually desensitize females and attentuate their sexual desire.² Circumcisions, in varying degrees of severity, are routinely inflicted on girls or young women, depending on the customs of the tribe and the geographic area, with or without the female's consent and usually by force.

Excision of the clitoris and parts or all of the labia minora are practiced in most of sub-Saharan Africa. These body parts generally are considered unclean and often are feared dangerous to the manhood of the husband and lethal to newborns. The culture regards excision as an essential purification rite.³

Although the Islamic religion does not prescribe or advocate female circumcision, the severest and most damaging circumcision practices are found among Arabic-Islamic peoples along the Horn of Africa, in an area encompassing Southern Egypt, Northern and Central Sudan, parts of Ethiopia and Kenya, Somalia, Djibouti, and Mali in Western Africa. In these areas. Infibulation, as well as excision, is practiced.⁴

Infibulation additionally involves the scraping out of the fleshy, inner layers of the labia majora. The remaining outer edges are brought together so that when the wound heals, the edges fuse together to leave only a pinhole-size opening, barely adequate for urinination and menstruation. The infibulation is, in effect, a chastity belt of thick fibrous scar tissue. When the female marries, here genitals are subject to further trauma by the bridegroom, who either tears or cuts the infibulation to make sexual penetration possible and then delays the healing of the wound by repeated intercourse. Further trauma occurs each time the female gives birth, when the infibulation must be incised anteriorly to permit the delivery of the newborn. Afterward the infibulation is again sewn shut.^1,5 Spontaneous infibulation frequently occurs among females whose clitorises have been excised but who have not been ritually infibulated.

The age at which a girl is subjected to circumcision may vary from early infancy to the birth of her first child, depending on the prevailing custom of the area or tribe. Throughout Africa, the tendency is to perform the surgery at younger ages because a small boy is more easily managed.⁶

A medically untrained midwife traditionally performs circumcision on an unanesthetized child. Several women hold the child immobile to keep her from struggling. Instruments used include razor blades, kitchen knives, scissors, and pieces of glass. Within recent years, some medical training has been made available to these practitioners, and in many African cities, circumcisions are now performed in a rudimentary clinic. Local anesthesia and antibiotics are used.

Health-care providers should be educated to cut the patient's circumcision scar during the second stage of labor to prevent tearing.

While these improved techniques tend to reduce fatalities and immediate postcircumcision complications, such as hemorrhage, infection, fever, and shock from pain, the long-term effects, particularly when infibulation occurs, are much the same. Long-term effects usually begin as chronic infections, due to a build up of urinary and menstrual debris behind the infibulation. These infections eventually may spread to the entire reproductive and renal systems. Other frequently seen complications include vulvar abscesses, inclusion cysts, fistulas, impossible penetration, and painful intercourse. Childbirth is more hazardous to the mother and neonate because massive and often keloidal scarring of the infibulation obstructs and prevents dilation.^5,7-9

Health-care practitioners might expect that with the increased exposure to Western culture and ideas in Africa, the incidence, or at least severity, of female circumcision would decrease significantly. So far, no significant decrease has been observed in any part of Africa.^1,10

The reasons for the continued use of female circumcision are manifold. Traditionally, the practice has been associated in many African cultures with marital chastity and, therefore, has been a prerequisite for marriage.¹¹ An uncircumcised woman will not find a man willing to marry her, and few, if any, options other than marriage or motherhood have been open to the African woman. In some cultures, such as in Sudan and Egypt, circumcision traditionally has been a guarantee of family honor and a sign of high social status within the community. The practice has served to differentiate the decent circumcised and infibulated woman form prostitutes and slaves.

When possible, a female physician or nurse should perform the pelvic examination on the circumcised woman

Parents fear leaving their daughters uncircumcised because that is equated with low-class status and dishonor and may lead to social ostracism from the tribe or clan. Circumcision increases the African girl's chances of contracting a favorable marriage and her family's chances of obtaining a high price for the bride.

The lives of the many circumcised and infibulated women in Africa tend to be characterized by predictable, recurring episodes of extreme anxiety due to anticipated and inescapable pain.¹² The anxiety begins with the anticipation of the circumcision, which more often than not, may be performed without anesthesia. The female experiences anxiety when she faces the prospect of marriage and having the infibulation torn or cut by the husband or midwife. During the initial marital period, after the infibulation is opened, sexual intercourse brings pain and anxiety until the wound heals. Each time a woman gives birth, the infibulation must be cut. Delivery without professional assistance may be life threatening because of obstruction by the inelastic scar tissue from the original infibulation. The infibulation usually is resutured after the delivery. The infibulated woman who needs care in the Western medical setting also experiences an entirely new source of anxiety (i.e., the likelihood that Western health-care providers will not know how to deal with the infibulated or circumcised woman's special problem).

Many women for countries where female circumcision is the norm visit or move to the United States, so nurses here may have opportunities to care for women who have been circumcised or infibulated. These women know that health-care providers in the United States know nothing about circumcised women's unique problems.

During interview sessions with several women who were infibulated as young girls, the women expressed hope that physicians and nurses would be knowledgeable about the custom of female circumcision and infibulation. They should know what I will look like and not ask me if I have been in an auto accident. They should know that the way I look is normal for me!¹³

The women interviewed also were concerned about pelvic examinations. These women dread pelvic examinations because most infibulations result in a tight introitus and may cause increased sensitivity to pain in the genital area. However, many women are taught not to express pain related to pelvic examinations, labor, and delivery. Although the women may not exhibit verbal or nonverbal responses to pain, they may later confide that their examination was excruciating.¹⁴

The health-care practitioner should make every effort to establish a rapport with the patient's husband, who may be the sole decision maker.

Genital examinations by male physicians or exposure of the patient in the presence of male trainees or practitioners may be considered demeaning or ever sexually abusive by persons from a culture that demands female health-care providers for its women. When dealing with circumcised women, health-care providers should remember that many of these patients come from cultures in which a woman must first obtain permission from a male family member before she can receive health care. If the examining physician is male, the woman can be prevented from being examined no matter how ill she may be. Whenever possible, female physicians and nurses should conduct the examinations. The caretaking practitioner must remember that these women's lives and reputations may depend on their demonstrated modesty.

Infibulated women who were interviewed expressed the hope that physicians and nurses would be knowledgeable about the widespread practice of circumcision and infibulation in their cultures.

Nursing traditionally prides itself on a family focus, which is doubly important when working with different cultures. Every effort must be made to establish a rapport with the male family member, who from his perspective, is doing everything he can to protect his wife, daughter, or sister. An excessively hasty and ill-considered application of Western medical standards to these patients and their families could be interpreted by them as a form of sexual and psychologic abuse.

 

 

The women interviewed feared receiving poor care during pregnancy, particularly at the time time of delivery.¹⁵ Because few health-care practitioners in the United States have had experiences with infibulation scars, the danger of severe tearing during the birthing process is real. If the delivery protocol used in countries where the majority of women are infibulated could be adapted for use in the United States, severe tears during actual delivery could be prevented. The following protocol has been shared by a physician from Sudan, who recommends that the circumcision scar, which consists of a flap of skin enclosing the upper part of the vestibule, be incised during the second stage of labor:

The index finger of the left hand is inserted through the introitus and directed to the pubis. After injecting a local anesthesia, the flap of skin anterior to it is raised (Figure 1). Using a pair of scissors this is cut in the mid-longitudinal line. The introitus is thus widened and the urethral opening exposed (Figure 2). If a finger cannot be inserted through the introitus, a small scar is first made at twelve o'clock, and after determining the upper limit of the flap, the incision is completed. If there is an indication for an episiotomy, this may also be performed.

In Sudan, after delivery the two edges of the decircumcision wound are approximated and sutured together in one layer using interrupted stitches of absorbable suture material (Figure 3).

The care of the wound is the same as that for an episiotomy. If this procedure is followed and the circumcision scar is cut before the usual episiotomy, the inelastic tissue will not be as likely to tear. Indeed, there may not be a need for a lower episiotomy to be done at all.¹⁶

 

 

Most of the women who give birth to their infants in the United States wish to have the circumcision area repaired: It is too late to change for me, and I want it redone for my my husband's sake.¹⁴ Occasionally a woman and her husband will ask for a less tight repair. There have been occasions in which a physician has not agreed to the repair desired and the family has chosen a less safe home birth with an untrained lay midwife or friends.¹⁴ The health-care practitioner must make an ethical decision. Some attempt should be made to inform or persuade the client and her husband of the health benefits of a less severe repair.

 

 

Fahtma feels strongly about this:

I have suffered a lot with the first two children that I had in Sudan. For 40 days, I could do nothing but lie it bed. I could not walk or do my housework because they had sewn me so tightly again. When I had my other two children in the United States, they sewed only what they had to, and after seven days I was as good as new. I had no problems at all.

Women in Africa traditionally have been regarded as property; they are now becoming aware of their human rights.⁷ Because circumcision practices are ubiquitous within circumcised women's limited spheres, the women cannot compare their condition with that of uncircumcised women. They accept the long-term health consequences of being circumcised as being simply a woman's lot.

While living in Africa under familial and tribal influences, a woman usually views her circumcision as a source of pride and community acceptance. Any painful and traumatic consequences she may suffer as an adult generally are not attributed by the woman to the procedure performed on her in childhood, especially if she was a small child when it was performed and, therefore does not remember it clearly. The woman has not reason to question the necessity or essential rightness of her own circumcision or the one that will be performed on her daughter.

When some circumcised women are exposed to Western culture, they experience profound shifts in awareness and orientation. The health-care practitioner who treats a female African patient should be aware of the patient's background and sensitive to any ambivalence. For example, the patient may find it difficult to discuss the subject of her circumcision with a Westerner, especially regarding her submissiveness to the custom. This is particularly true if she is an educated woman.

Nursing Implications

Nurses can incorporate the information provided in this article in a variety of ways to improve their practice and better meet the needs of the infibulated patient and her family. Because the infibulated woman may not exhibit verbal or non-verbal responses to pain, nurses should not expect cues expressing discomfort. They should make every effort to ensure that pelvic examinations are made as comfortable and free of stress as possible. Utmost privacy must be maintained and careful draping used whenever possible to provide maximum coverage for the woman. Above all, the health-care provider should be female.

Before conducting the pelvic examination, the health-care provider should teach relaxation techniques to the patient. Pictures and anatomic models can also be used to explain to the patient and her husband the procedures that are performed. Because the husband may need to give continuing permission for any medical treatment his wife is to receive, his involvement and understanding are crucial.

To increase comfort during the pelvic examination, the health-care provider can use a warmed pediatric speculum and conduct a bimanual examination using a single finger and a rectal examination to palpate the uterus and ovaries. If indicated, ultrasound may be helpful in determining the size and regularity of the uterus and ovaries.

If the patient has difficulty urinating after delivery, the catheterization procedure may need to be modified. The female nurse must remember that she can insert her finger under the scar tissue and retract it gently to locate the urinary meatus. Usually, enough tissue relaxation will occur after delivery to allow for the fitting of a diaphragm or IUD if the woman wishes one of these contraceptive methods.

Nurses need to be knowledgeable about the health practices and cultural backgrounds of circumcised women And be willing to bridge the cultural gap between the patient and health-care providers in the United States.

Women in African societies highly respect nurses and midwives because they are the women's primary sources of medical service and are thus believed to hold the power of life or death. Therefore, female nurses in the United States can serve as potential educators. African patients need to be informed of the harmful effects of circumcision, and particularly infibulation, an a woman's health so that they can make an educated choice regarding their daughters.¹⁷ The nurse can be a valuable source of information and can bridge the gap between the infibulated African woman's life experiences and those of uncircumised women in Western society. The situation requires great understanding and empathy from the nurse, as well as current factual knowledge of the circumcised woman's cultural and medical needs.

Summary

This article has discussed the special needs of ritually circumcised and infibulated female patients. The practice of female circumcision has been described within its cultural context. Because nurses in the United States may have opportunities to care for circumcised patients, specific information has been presented, aimed at enabling nurses to render the most effective help possible with respect to the patients' highly specialized needs. The nurse's role is described as being a multiple one and includes that of advocate, educator, cultural liaison, and skilled knowledgeable professional.

Address for correspondence: Hanny Lightfoot-Klein, MA, P.O. Box 335, Arivaca, AZ 85601

Hanny Lightfoot-Klein is an independent anthropologic sexologist, family counselor, and former educator living in Arivaca, Arizona. Ms. Lightfoot-Klein is a member of the  Association for Women in Psychology, the  Society for the Scientific Study of Sex, and the  Society for Sex Therapy and Research.

Evelyn Shaw is a community health nurse, school nurse, and educator in the  College of Nursing at the University of Arizona, Tucson. Ms. Shaw is a member of the  American Nurses' Association, the National Association of College Health, and  Sigma Theta Tau.

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