By Mary Katherine Keown
    Women's eNews

    Friday 10 August 2007

    Arusha, Tanzania - 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 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 Web site. "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 National Union of Djiboutian Women - who asked to remain anonymous due to the dangers of opposing FGM - told Women's eNews 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, indicates that in several countries in Africa where FGM is common - including Somalia, Sudan, Tanzania and Djibouti - between 55 and 60 percent of HIV-infected individuals are female.

    Mounting Body of 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 links between FGM and increased rates of obstetric fistula and maternal mortality have often been a focus of previous research, but a study published in AIDS Patient Care and STDs, a monthly peer-reviewed journal in New Rochelle, N.Y., was presented at a 1998 international AIDS conference and drew some attention to the HIV issue.

    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," according to the WHO Web site.

    FGM Conference in Ethiopia

    At a meeting last week in Addis Ababa, Ethiopia, hosted by the United Nations Population Fund, delegates called on religious and traditional leaders to educate their constituencies on the dangers of FGM, but did not highlight a higher risk of HIV infection as a result of the procedure.

    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 percent and 97 percent 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.

    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 percent 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 percent of FGM cases involved infibulation.

    Djibouti has an HIV prevalence rate of approximately 3 percent (of an estimated population of 793,000), according to a 2006 report from UNAIDS, the Joint United Nations Program on HIV-AIDS. Sixty percent of adults living with HIV-AIDS (aged 15 and up) are female and around 98 percent of females in the country are subjected to some form of FGM.

    Outlawed Practice Continues

    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."

    Several girls may be cut in quick succession by village elders, under unsanitary conditions and without sterilizing instruments between procedures. She also asserts that FGM makes women more vulnerable to vaginal tearing during sex, as they lack the ability to produce natural lubrication. Tearing, in turn, allows for passage of the virus into the bloodstream.

    Michael Reuben, a program officer with the Network Against Female Genital Mutilation, based in Moshi, Tanzania, 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.

    Reuben notes that FGM is 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."

    United Nations Population Fund, FGM conference:
    http://www.unfpa.org/gender/fgm2007/

    The World Health Organization:
    http://www.who.int/en/

    The Female Genital Cutting Education and Networking Project:
    http://www.fgmnetwork.org/index.php