Health consequences of female genital mutilation/cutting in the Gambia, evidence into action
Health consequences of female genital mutilation/cutting in the Gambia, evidence into action
Adriana Kaplan 0 1 2 3
Suiberto Hechavarra 5 6 7
Miguel Martn 4
Isabelle Bonhoure 2
0 Catedra de Transferencia del Conocimiento/Parc de Recerca UAB-Santander, Departamento de Antropologia Social y Cultural, Universitat Autonoma de Barcelona , Barcelona , Spain
1 NGO Wassu Gambia Kafo, Fajara F Section , Banjul , The Gambia
2 Grupo Interdisciplinar para la Prevencion y el Estudio de las Practicas Tradicionales Perjudiciales (GIPE/PTP), Departamento de Antropologia Social y Cultural, Facultad de Letras y Psicologia, Universitat Autonoma de Barcelona , Barcelona , Spain
3 Catedra de Transferencia del Conocimiento/Parc de Recerca UAB-Santander, Departamento de Antropologia Social y Cultural, Universitat Autonoma de Barcelona , Barcelona , Spain
4 Grups de Recerca d'America i Africa Llatines (GRAAL), Unitat de Bioestadistica. Facultat de Medicina, Universitat Autonoma de Barcelona , Barcelona , Spain
5 Facultad de Ciencias Medicas Manuel Fajardo. Universidad Medica de la Habana , La Habana , Cuba
6 Community Based Medical Program, Ministry of Health and Social Welfare , Banjul , The Gambia
7 Cuban Medical Mission in The Gambia , Banjul , The Gambia
Background: Female Genital Mutilation/Cutting (FGM/C) is a harmful traditional practice with severe health complications, deeply rooted in many Sub-Saharan African countries. In The Gambia, the prevalence of FGM/C is 78.3% in women aged between 15 and 49 years. The objective of this study is to perform a first evaluation of the magnitude of the health consequences of FGM/C in The Gambia. Methods: Data were collected on types of FGM/C and health consequences of each type of FGM/C from 871 female patients who consulted for any problem requiring a medical gynaecologic examination and who had undergone FGM/C in The Gambia. Results: The prevalence of patients with different types of FGM/C were: type I, 66.2%; type II, 26.3%; and type III, 7.5%. Complications due to FGM/C were found in 299 of the 871 patients (34.3%). Even type I, the form of FGM/C of least anatomical extent, presented complications in 1 of 5 girls and women examined. Conclusion: This study shows that FGM/C is still practiced in all the six regions of The Gambia, the most common form being type I, followed by type II. All forms of FGM/C, including type I, produce significantly high percentages of complications, especially infections.
Female Genital Mutilation/Cutting; Gambia; Sexual and Reproductive Health; Africa
Female Genital Mutilation/Cutting (FGM/C) refers to
all procedures involving partial or total removal of the
external female genitalia or other injury to the female
genital organs for non-medical reasons . It is
recognized internationally as a violation of the human rights
of girls and women and constitutes an extreme form of
discrimination against women due to the severe health
consequences and the pain and risks involved.
WHO calculates that between 100-140 million women
and girls in the world have been victims of some kind
of FGM/C and that each year about 3 million girls are
at risk or are subjected to some kind of FGM/C,
essentially in 28 countries in sub-Saharan Africa, northern
Iraq (Kurdistan), Malaysia and Indonesia, plus Europe,
USA and Australia among many other countries where
migrants carry along their culture [2,3]. In many
societies it is a rite of passage to womanhood with strong,
ancestral sociocultural roots. Rationalizations for the
perpetuation of FGM/C include: preservation of ethnic
and gender identity, femininity, female purity/virginity
and family honour"; maintenance of cleanliness and
health; and assurance of womens marriageability [4,5].
In the Gambia, FGM/C is carried out in girls aged
between birth (7 days) up to pre-adolescence, always
before the first menstruation and marriage [6-9].
According to the WHO classification of 1995 
used in this study designed in November 2008, FGM/C
can be divided into four types:
Type I: Excision of the prepuce and part or all of the
Type II: Excision of the prepuce and clitoris together
with partial or total excision of the labia minora.
Type III: Infibulation. Excision of part or all of the
external genitalia and stitching together of the two cut
sides, to varying degrees.
Type IV: Pricking, piercing, incision, stretching,
scraping, or other procedures harming the clitoris or labia, or
Types I, II and III of FGM/C present severe health
consequences that have been well documented by
several authors. The immediate health complications
include shock, haemorrhage, infections and
psychological consequences [11-13]. The long term health risks
consist of chronic pain, infections, cheloids formation,
primary infertility, birth complications, danger to the
new born and psychological consequences [13-18]. Even
FGM/C types I and II, sometimes considered as more
innocuous, may involve severe health complications. For
example, they have been reported to provoke
unequivocal complications like shock, haemorrhage, urogenital
complications , obstetric complications  and
sexual dysfunction .
Despite the documented adverse effects of FGM/C, a
recent review article states that its overall prevalence
has declined very little .
In the case of The Gambia, the survey MICS 2006
shows that the prevalence of FGM/C remains as high as
78.3% in women aged between 15 and 49 years . In
1999, Morison et al. conducted a community-based
survey on the long-term health consequences of FGM/C in
rural Gambia . The conclusions were that women
who had undergone FGM/C had higher prevalence of
bacterial vaginosis and of herpes simplex virus 2 (HSV2).
Nevertheless, knowledge about the extent of health
consequences of FGM/C in The Gambia is scarce.
This issue has political and religious implications since
the government of The Gambia asked for medical
proofs on the harmfulness of the practice in order to
permit making an informed statement based on local
evidence and taking further steps. The request for this
study to be conducted was made by the Vice-President
and Minister of Womens Affairs, Dr. Aja Isatou
NjieSaidy. The clinical evidence will lend support to the
political will to prevent the practice of FGM/C in The
Gambia through education and legislation.
Thus, the main purpose of the present study is to analyze
the health consequences of FGM/C in patients who
spontaneously sought medical care. The specific objectives are
to: 1) find out if the practice still exists in the country 2)
determine which types of FGM/C are practiced 3)
determine what health problems are associated to each type.
Thus, the study has been designed to permit
ascertaining FGM/C types and health consequences directly,
through a medical examination. The data has been
collected during 4 months (December 2008 to March
2009) in hospitals and major health centres throughout
the country, achieving a total of 871 cases of women
and girls that have undergone the practice.
women and girls who sought consultation for whatever
problem requiring a medical gynaecological examination
and who had undergone FGM/C. As there is no national
health register, it was impossible to determine the total
number of medical consultations during study period,
consequently making it impossible to calculate
morbidity and mortality indices.
The data has been collected by Cuban doctors,
specialized in General Comprehensive Medicine and
Gynaecologists, working in The Gambia on a humanitarian
mission. These doctors were previously trained in order
to be able to clearly identify the different types of FGM/
The data analyzed here are obtained from secondary
data as a result of patients spontaneous demand and
consequently the use of the data no required previous
information to the patient. Furthermore, the research
team, in agreement with the Gambian health authorities,
collected data anonymously.
After the doctors visited the patients, the information
was collected in a clinical form specially designed for
the study. They could not guarantee that the data was
recorded exhaustively due to the inadequate conditions
of the health facilities and the over demand of medical
services. This survey provides a raw picture and is the
preliminary step to conducting a more complete clinical
survey, covering complications during delivery and foetal
The types and complications of FGM/C were assessed
by direct clinical exam of the genitalia. The review took
place only in medical facilities (consultations and
delivery rooms). For every patient with FGM/C that had
haemorrhage and or anaemia as their chief complaint, a
FBC (Full Blood Count) was done to confirm if they
were anaemic or not. The infections were diagnosed
clinically, and any long term complications expressed by
the patients were also recorded, although none of them
associated their complaint to the practice they
undergone when they were young, except for girls who came
immediately after FGM/C had been performed. The
clinical examination only was done if the patient
reported a medical problem requiring a medical
1. Demographic Variables
- Registration place: Patients region of residence. All
six regions in The Gambia: Upper River, Central
River, Low River, North Bank, Western and Greater
- Ethnic group: Mandinga, Wolof, Fula, Djola,
Saraholes, Serer and Others.
2. Clinical variables (qualitative variables)
- Type of cutting (ordinal). Categories of this
variable were those defined by WHO in 1995. Type IV
was not included in the study.
- Complications. Complications in patients with
cuttings, dichotomized variable (yes/no). Complications
were also classified, according to the time when they
Immediate. Patients in who cutting was recent,
with signs of complication appearing in the next
few hours and up to 10 days after cutting was
Long Term. Complications appeared more than
10 days later, and were more related with
pregnancy affectations during labour or childbirth
- Type of complications. Depending on aetiology, the
complications can be:
Haemorrhage. Excessive bleeding from genitalia
because of this cause.
Acute Anaemia. Considered in this study if the
patient presented symptomatology suggesting
anaemia, as a consequence of haemorrhage due
to the cutting. Based on the results of the
differential FBC, a patient was considered anaemic if
their haemoglobin level was below 11 g/l, and
Infections. Invasion and spreading of pathogenic
micro organisms, divided into:
- Tetanus: Presence of fits or convulsions,
- Repetitive infections of low urinary tract.
- Infection of the urethral mucus and/or
- Septicaemia: Colonization of the blood by
bacteria with a lethal systemic infectious
- Vulvovaginitis: Acute inflammation of the
vaginal mucus characterized by burnings,
itching, redness and excoriation due to rash
with or without leucorrhoea.
- Fibrosis: Pathologic formation of fibrous
tissue in the genitalia due to an abnormal
scarring or cicatrisation of cuts, i.e. limited to the
site of cutting.
- Cheloids. Excessive growth of scar tissue at
the site of a skin lesion that has just healed.
Characterized by an abnormal growth of the
tissue over the place of the cutting.
- Synechia: Adherence and abnormal fusion
which may be partial or total, of the major or
- Tissue rotation: Due to the tissue lost with
abnormal scarring and retraction of
Organic dispareunia: Gynaecological
complication characterized by pain during intercourse due
to the cutting.
Statistical treatment of the data
The data have been analysed in aggregated crosstabs
classifications looking for the major associations
between type of FGM/C and possible health injuries as
listed above. Chi square tests of association were
calculated and partial binomial and multinomial distributions
This survey was done at the request of the Gambian
government. The clinical register was kept under the
custody of the medical personnel in charge of that issue,
and under rigorous confidentiality.
Data was collected on a total of 871 cases, throughout the
country. The types of FGM/C and health complications
deriving from them are summarized in Table 1. Type I
FGM/C accounted for 66.2% of the cases registered, and
type II 26.3%. Type III had a much lower prevalence,
7.5%. A substantial number of cases were observed with
health complications arising directly from the practice of
FGM/C. Complications, whether immediate or late, were
present in 23.7% of the patients with type I FGM/C (137/
577), in 55.0% of patients with type II (126/229) and in
55.4% of patients with type III (36/65). The most
common immediate complication, for all types, was infection,
associated in some cases with haemorrhage and anaemia.
110 patients out of the 871 registered patients, i.e. 12.6%,
sought consultation for an immediate complication of
FGM/C. The late complications were observed in 189
patients out of 871 patients, 21.7%. In total, 299 out of
871 registered patients with FGM/C who sought a
gynaecological consultation (34.3%), presented immediate or
late complications due to FGM/C.
Total complications directly arising from FGM/Ca
Table 1 Number of cases by FGM/C types, complications (total, immediate and late) and types of complications
a.- of the total cases, b.- of the total complications (immediate and late) c.- of the total immediate complications, d.- of the total late complications.
These findings, and in particular the immediate
complications presented by young girls, demonstrates that
FGM/C is still practiced in all the six regions of The
The clinical examinations evidenced that, out of the
women and girls who presented signs of FGM/C, the
majority had FGM/C type I (66.2%), followed by type II
(26.3%) and type III (7.5%). The results present
discrepancies with Morisons survey, in which 98% of the
women that presented FGM/C had type II . As that
study was performed in a specific area, Farafenni
(Northbank East), direct comparison with the present
work, covering the whole country, is not possible.
However, the percentages of type I and II are comparable
with others studies performed in West Africa, namely
Ghana and Nigeria [22,23] and with the fact that FGM/
C type III is only the most prevalent form in East Africa.
Another finding of this survey is that all the forms of
FGM/C, including type I, are responsible for a high
percentage of complications, both immediate and late. In
this study, 110 immediate complications and 189 late
complications, out of 871 cases, were observed. In
particular, immediate FGM/C complications, reported
previously [11,12], appear to be significant in this study. It
has to be noted that even type I FGM/C, the form of
FGM/C with least anatomical extent, presented
complications in 1 of every 5 girls and women who consulted.
Complications in type II FGM/C were observed in 1 of
every 2 girls and women examined, thus confirming the
previous finding that the prevalence of health
consequences are proportional to the anatomical extent of
FGM/C . For type III, which was only present in a
total of 65 patients, complications are also observed in 1
of every 2 girls and women. However, because of the
size of the sample for type III, this figure could be 2 of
every 3, i.e. corresponding to the upper limit of CI95%. It
has to be stressed that these figures are purely indicative
as the patients are not necessarily representative of all
girls and women who have undergone the practice of
FGM/C. Nevertheless, these results give a first hint of
the frequency of health consequences arising from any
form of FGM/C in The Gambia. Moreover, the results
that we report only include girls and women who had
access to a medical facility, something which is difficult
for most of the rural population. In The Gambia, the
majority of the population live in rural areas, often
badly communicated and far from any dispensary, where
the prevalence of FGM/C has been documented to be
higher, and in the eastern regions, almost universal .
For this rural population, it can be hypothesized that
the health consequences related to FGM/C are more
severe due to the lack of adequate medical care
postintervention as previously stated by other authors 
and as it was demonstrated for others reproductive
organ pathologies  and for maternal mortality in
rural Gambia [25,26].
This study also indicates that the practice of FGM/C
has a significant economic cost as 1 of 3 patients (299
cases of 871) suffered medical consequences requiring
treatment. This finding was corroborated by a recent
study showing that the annual costs of FGM/C-related
obstetric complications ranged from 0.1 to 1% of
government spending on health for women aged 15-45
years. Moreover, in the six African countries where the
study was done, e.g. Burkina Faso, Ghana, Kenya,
Nigeria, Senegal and Sudan, a loss of 130,000 life years
is expected owing to FGM/Cs association with obstetric
Given such adverse effects, one is tempted to ask why
the practice of FGM/C is still continuing. Certainly, one
of the reasons would be that FGM/C has strong
ancestral socio-cultural roots as evidenced by the fact that
72.9% of the Gambian women would like their
daughters to undergo FGM/C . Another reason is
probably the lack of knowledge regarding health
consequences associated with FGM/C, even among local
health professionals like nurses or midwifes regarded by
a recent review as a specific target to be addressed in
order to favour abandonment of the practice . These
preliminary results will allow the implementation of a
national training work plan for the health professionals
and students regarding the issue of FGM/C, directly
based on the observed health consequences in The
FGM/C is still practiced in all the six regions of the
country and resulted in various forms of damage/injury
in 1 of every 3 of the women examined.
The form of FGM/C most commonly practiced in The
Gambia is type I, followed by type II. All forms of FGM/
C, even type I, lead to a high percentage of
complications, especially the infections associated with
haemorrhage and anaemia. The frequency of complications
increases with the degree of mutilation/cutting.
This study has been possible due to political implication of the Gambian
Government, through the Vice-President and Ministry of Womens Affairs
and the Ministry of Health.
Thanks to the Cuban Medical Mission in The Gambia for its participation in
the study design and in the data collection.
We are grateful to the Fundaci La Caixa that sponsored the project and to
the NGO Wassu Gambia Kafo, for its support.
AK performed the previous studies about FGM/C, proposed and designed
the clinical study on health consequences of FGM/C in The Gambia,
performed the training of the medical doctors in the field and participated
to the data treatment and analysis.
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