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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.
"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.
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.
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."
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 per cent 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.
"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."
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.
"FGM enhances male sexuality, while preventing promiscuity and preserving virginity," says Reuben. "It minimizes sexual desire and feelings on the part of women, and thereby discourages prostitution. It is also performed because the clitoris is viewed as unhealthy."
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."
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.
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.
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."
By Mary Katherine Keown
Arusha Times (Arusha)
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