Infibulation in the Horn of Africa
Guy Pieters, M.D.
Albert B. Lowenfels, M.D., F.A.C.S.In the arid, poverty-stricken "Horn of Africa" a remarkable gynecological custom called infibulation persists. Jutting out into the Indian Ocean, this part of Africa is separated from the remainder of the continent by desert to the north, mountains to the west, and by the tsetse-fly belt in the south. Here, some 5 million isolated inhabitants of Somalia eke out a marginal living by following their herds of sheep, camel, and cattle in search of pasture and water.
Definition
The word "infibulation" is derived from the Latin word "fibula," meaning a pin or clasp. The term has been given to a mulative procedure in which the vagina is partially closed by approximating the labia majora in the midline. Clitoridectomy may or may not be included, but the essential part of the operation consists of partial closure of the vulva and the vaginal orifice. The custom is deeply rooted in the country and has been performed since remotest time on all social classes in both the interior regions and in the few coastal towns.In Somaliland and the southern tip of the Arabian peninsula, the procedure has been freely performed on prepubertal girls and, therefore, at present there are millions of women whose external genitalia have been altered. Indeed, anthropologists call the "the land of the sewn women".1
Other ritual sexual operations sometimes performed in Africa include male and female circumcision, clitoridectomy, and ritual excision of the labia. These operations differ from infibulation in that they do not attempt to cover the vaginal orifice.
Origin of custom
Where did such an unusual custom arise? Since early Arabian writers do mention infibulation and clitoridectomy, it seems likely that infibulation originated in southern Arabia and from there spread to Africa. For hundreds of years these two regions, although separated by the Gulf of Aden, have had close contact so that the custom could have spread along well-established trade route. High mountains and an almost impenetrable desert would have prevented this strange procedure from spreading into northern Arabia and the Yemen.Why was this mutilative procedure adopted by a whole population group? Hygienic reason seem unlikely because, if anything, infibulation makes personal hygiene more difficult. Cosmetic reasons can be discounted since the operation does nothing to increase the attractiveness of the pudendal region. The operation would certainly make the woman less sexually active, since satisfactory coitus is almost impossible after infibulation.
Perhaps infibulation represents a primitive effort to prevent evil spirits from entering the woman's body her vagina. Belief in evil spirits is part of almost every religion, and infibulation may be an example of an ancient superstitution.
Description of Procedure
The operation is performed by a male nurse who has been recognized as having the necessary skill to do the procedure. Usually about a dozen children from four to eight years old are treated per session. The operations are often done on Sunday, a working day for Moslems. Quite frequently, as infibulation is proceeding in one corner of the operation room, a group of young boys will be circumcised in the same room by a second team.
A local anesthetic is injected into the labia and the base of the clitoris. Then, using curved scissors, a small strip of labia is cut away on both sides leaving two raw surfaces about 2 to 3 cm. In length and 3 to 4 mm. In width. The labia are then sutured together with catgut and silk so that the vaginal orifice is narrowed to about the size of a pencil. Complications such as infection or hemorrhage are rare, although sometimes the raw surfaces do separate.
Since the population is largely nomadic, most operations are carried out in local villages. Infibulation as practiced in the bush is carried out on one child at a time by a "gedda" or matron of the village. Only women are allowed to be present at the ceremony which is carried out in secrecy. The matron squats on the floor of the family hut while the child is held in a lithotomy position by female relatives and friends. Again, the clitoris and labia are excised, but no anesthesia is used. Before the wound is closed, the mother and all the other women are allowed to inspect and palpate the wound to be sure the procedure has been properly performed. Then the wound is generously sprinkled with myrrh, a resinous material extracted from a native tree. Instead of sutures, thorns from an acacia bush are often used to close the wounds, and in addition, the girl's legs are tied together with rope for about two weeks. After that, the restraints are removed and the child is free to run about again.
Infibulation replaces the vulva with an almost solid wall of flesh that joins the thighs from the pubis nearly to the anus, with the exception of a small orifice at the inferior portion of the vulva. In some areas of the country, a reverse infibulation is carried out; the residual opening is placed in the anterior part of the vulva in front of the urethral orifice and the clitoris. Although clitoridectomy is usually included, the important part is closing the vulva and vagina.
Consequences of Infibulation
Effects on Marriage
In Somali the usual age of girls at the time of marriage is from 12-16 years, or nearly a decade after infibulation. Polygamy is still practiced and divorce is easy to obtain. Marriages are arranged by the family of the bride in exchange for a gift, usually money or livestock.Once the bargain has been made, the bridegroom's mother or sister examines the prospective bride to be sure the infibulation is intact. Little attention is given to the hymen, which, indeed, would be difficult to visualize behind the infibulation.
No matter how virile the husband, consummation of the marriage is nearly impossible because of the surgically created barrier. Therefore, in most marriages, the husband or one his female relatives will enlarge the vaginal opening with a small knife so that sexual intercourse can take place. It is the responsibility of the husband's female relatives to examine the bride a few weeks after the marriage, and if necessary, to enlarge the vaginal opening to permit intercourse.
Effects on Childbirth
The enlargement made when the marriage is consummated is too small to allow normal vaginal delivery. Therefore, at the time of childbirth, the infibulation must again be opened, and this time opened widely. In the villages, the grandmother, who functions as midwife, passes a small knife between the head and the inner wall of the infibulation, completely separating the labia. As soon as delivery takes place, the infibulation must be restored, using thorns or simple sutures to hold the tissues together. Once again, the legs are tied together to promote healing. With each subsequent delivery the entire process must be repeated.When deliveries are performed in a hospital, the infibulation is spared by enlarging the vaginal orifice with one or more deep episiotomies. To preserve the infibulation, the physician often has to perform an episiotomy when, ordinarily, it would be unnecessary.
Following a hospital delivery the patient insists that the vaginal orifice be tightly closed so that her husband will not repudiate her. If the resuturing of the episiotomy is unsatisfactory or if the opening is too large, the woman will invariably return for a plastic surgery.
Gynecologic Problems
Hemorrhage and infection sometimes occur when infibulation is carried out in the bush. Fortunately, despite the crude methods employed, both complications are rare.Large, painful suprapubic inclusions cysts sometimes form after infibulation and can be easily excised. In similar fashion, unsightly hypertrophic scars also may require excision.
If the vagina has been closed too tightly hematocolpos will develop at the time of onset of menstruation and must be relieved by opening the adherent labia.
Urinary retention is another complication that results from obstruction of the external orifice. Stones formed in the vagina and the patient also suffered from pyelonephritis.
As might be expected, accidental injuries to the vagina and the bladder during separation of the infibulation at the time of the delivery are frequent and these injuries often cause troublesome vesicovaginal fistulas.
Occasionally, a women who has had an infibulation performed in early childhood where the procedure is unknown 2-4. Inspection of the genitals reveals the typical partially closed vaginal orifice and the patient will give a history of a ritual operation in childhood. Separation of the infibulation will be necessary to alleviate the gynecologic problem or to allow vaginal delivery.
Summary
Infibulation is the term given to a primitive sexual operation in which the labia are approximated to obstruct the vagina. The custom persists in the Horn of Africa and southern Arabia despite the obvious psychologic, obstetric, and gynecological problems that it creates. It can only be hoped that with increasing education and social enlightenment this mutative procedure will soon be abandoned.
References
- de Villeneuve, A.: Etude sur une coutome Somalie, les femmes cousues, Journal. Social. African, v7:15 (1937).
- Daw, E.: Female circumcision and infibulation complicating delivery, Practitioner, 204:559 (1970).
- Dewhurst, C.J., and Michealson, A.: Brit. Med. Jour., 2:1442 (1964)
- Mustafa, A.Z.: Female circumcision and infibulation in the Sudan, Journal. Obs. & Gynaec. Brit. Comm., v73:302 (1966).
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