Département des Sciences sociales, Domaine Sciences des sociétés, des cultures et des religions, Université de Fribourg, Bd Pérolles 90 CH-1700 Fribourg, Switzerland
Submitted date: September 19, 2017; Accepted date: October 10, 2017; Published date: October 17, 2017
Purpose: Based on two instances of qualitative research, this paper aims to develop some considerations on the meanings given by women to the term “reparation” after female genital mutilation/cutting (FGM/C). The various aspects involved and the importance of integrating a comprehensive approach in medicine are all explored.
Methods: Semi-structured, in-depth interviews were conducted with a group of 8 immigrant women of sub-Saharan origin living in Switzerland with Type III FGM/C (infibulation) and 32 first and second generation immigrant women living in France with Type II FGM/C (excision) who have undergone or asked for clitoral reconstruction. In total 40 women were questioned on the meaning they give to the term “reparation” within their health and sexual life.
Results: While the group of women with infibulation and the group of women with excision differed in their sociodemographic characteristics and the context of FGM/C, both groups affirmed their desire to improve, or at least change, their condition. Reparative approaches were then evoked by women who would "repair" something "lost" or "stolen"; the word" reparation" acquires a wide range of meanings and dimensions which are not only physical, but also psychosexual, social and moral.
Conclusion: Specific healthcare services in term of reparative approach allow for the development of a discussion with women with FGM/C. Medicine is called upon to engage in a dialogue with the patients and their narratives. Reparative approaches may be able to offer more comprehensive healthcare and take an ethical stand when an element of injustice is present.
Reparation; Healthcare; Diversity; Counseling; Female genital mutilation/cutting (FGM/C)
Women from sub-Saharan Africa living in European countries have started to speak out about female genital mutilation/cutting (FGM/C) and ask for specific healthcare when they are affected [1-4]. The international socio-political context is openly against these traditional practices, which are performed by many ethnic groups in different African countries [5-7]. While recent research shows that FGM/C is present in other geographical areas, such as Yemen, Iraq and Indonesia, the prevalence and the concentration of FGM/C remain highest in sub-Saharan regions. The African continent has been the target of many public health campaigns over the years, which have contributed to shaping the perception of the practice among the populations exposed to such campaigns [8-12]. While the main aims of those campaigns were to eliminate FGM/C, the messages have often been very aggressive and have had different side effects. Some scholars have pointed out that these campaigns helped to represent “excision” and “infibulation” as specifically African gynecological problems that created bias in healthcare professionals during diagnosis [13-15]. Others have shown that African women, especially in diaspora, have seen their body image, their self-esteem or their gender model undermined because of the stigmatisation of the practice in a migratory context [16-20].
Since the end of 1990s, FGM/C has been defined as a “harmful practice” and great efforts have been employed both the South and in the North in order to prevent such practices being performed on children [21,22]. For more than three decades FGM/C has been considered to cause “irreversible damage” to women’s sexual and reproductive health. The introduction of clitoral reconstructive surgery, a surgical technique aiming to restore the “original body” and repair the cut clitoris, was a turning point. This surgery aims to reconstruct a normal looking clitoris, which is re-located in the correct anatomical position and potentially functional with respect to its innervation [23,24]. While the issue of surgical protocol is still being discussed and evidence examined reconstructive surgery has shaken the paradigm of “irreversible damages” and opened up possibilities of reconstruction [17,25-27]. Although many medical studies have reported and documented the side effects and benefits of reconstructive surgery, this article will look at the sociological impact of reconstructive surgery on women's perceptions and meanings of “reparation”.
Studies have shown that resection of the clitoral fibrosis, and easier access to the clitoris itself, might improve both pleasure and pain [25-28]. Other authors have underlined the implications of reconstruction for both gender identity and body image . Other researchers have shown that the operation is an opportunity for many women to question and re-evaluate the traditional values that they have been taught by their families [26-30]. The management of African women with FGM/C started to acquire a multidisciplinary approach, where medicine began to develop the psychosexual, ethical, moral and social dimensions of healthcare [31,32]. Few studies have analysed multidimensional healthcare and women’s needs.
The management of FGM/C varies from national healthcare systems in different European countries, multidisciplinary protocols are becoming more commonly adopted, and specific counseling is encouraged [1,32]. Within counseling, women with FGM/C are expected to undergo an important reflexive process. They are expected to review and reconsider not only the traditions and parental norms but also their own bodies . In this process of reconstruction they see a different meaning of “reparation” which this article intends to highlight.
The process of reconstruction involves several aspects (biological, emotional, moral, psychological, sexual) that women invest with different meanings. During this process, which I call the “pathway to reconstruction”; healthcare professionals are called upon to play a multidisciplinary and ethical role .
Analysis of the term “reparation” is based on two instances of qualitative research, conducted in France (from 2008-2009) and in Switzerland (from 2013-2014). In total 40 women were interviewed: 8 immigrant women of sub-Saharan origin living in Switzerland with Type III FGM/C (infibulation) and 32 first and second generation immigrant women living in France with Type II FGM/C (excision) who have undergone or asked for clitoral reconstruction in a public hospital. All the women were questioned on the meaning they attach to the term “reparation” within their health and sexual life.
Semi-directed in-depth interviews were conducted within a hospital. All interviews were recorded and transcribed in their entirety by the researcher. The collected data allowed for content analysis, based on thematic categories, produced by manual coding . The hospital was chosen as the place for research for various reasons: it both allowed contact with a “hard to reach” population (ref) and to deal with sensitive subjects (intimacy, sexuality, excision and infibulation). Different topics were explored using a structured questionnaire (including both openended and directed questions). In this article I will only analyse the meanings attributed by women to the term “reparation” and the link that they establish with their healthcare request.
Given the linguistic and cultural barriers between the researcher and the participants in the Swiss context (almost all of the women spoke only one African language), a specific interpreter trained on issues relating to FGM was solicited.
The group of women with infibulation and the group of women with excision differ in their socio-demographic characteristics and the context of FGM/C. The diseases and type of pain reported were also interpreted or explained differently. This article does not focus on this aspect, but on the women’s requests to change their health condition, which they all stated in the interview. Once questioned on the possibilities of changing something in their life linked to their self-perceived health, all of the women stated that they would improve their health status, in particular their sexual health. When asked to define what they intend to change as well as to define the term “reparation” within their health and sexual life, many aspects were cited. Reparative approaches included a range of approaches, which were not only physical, but also psychosexual, social and moral. Two or even more dimensions could be present in a woman’s request for reparation, whose meaning is not exclusive but sometimes contains more than one dimension.
The most evident and most cited meaning of “reparation” is physical reconstruction by a surgeon. This request originates from the women’s feelings of “having been damaged” and the feeling that something is "missing" from their body. The women reported the sensation of feeling “limited” in their activities especially when they were asked to be naked (in changing rooms at a gym, at a swimming pool, etc.) or during intimate encounters with a partner. The request to be reconstructed is intended as the desire to reconstruct what has been cut. In particular, women with Type 2 (Excision) from the French group expressed the need to have their clitoris reconstructed.
The second meaning is linked to the feeling of “missing”, which becomes more complex when women report the idea of loss and theft. As they report, the practice of FGM/C is almost always performed on very young girls, most of them younger than 5, and a great number of women have no memory of this event. These women said that they “discovered” their FGM/C later, during adulthood or during their first sexual experiences. They clearly expressed the feeling that “something has been taken away without asking” or that something had been “stolen” from their body without their consent. They underline the feeling of loss of bodily integrity, which is accompanied by the feeling of having been subjected to a violent experience and abuse. The feeling that something has been “lost” or “stolen” nurtures the feeling of deserving justice, which becomes, for some of them, an explicit claim. This meaning underlines the moral dimension of the reparation which is, on the other hand, very often evoked in consultation- both by women and doctors as they report - with the term of “symbolic reparation”. Sometimes women say that what counts for them is “to have their clitoris back, even if it doesn’t work” as some of them have stated.
The third meaning of reparation is the sexual dimension. In particular, the excised women in the French group expressed their dissatisfaction, some of them defining themselves as “unhappy” with their sexual experiences. The majority specified that they were in a relationship with a European male partner, who, in most cases, was not familiar with the practice of FGM/C. Few women ask for “more pleasure” or “different pleasures”, lack of which is attributable to damages to the clitoris.
The last dimension concerns gender. In their meaning of “reparation” some women underlined that the bodies they have do not correspond to the body they want. This is particularly so for the second-generation women, who were born or arrived in European countries at a very early age and grew up outside of an African context. This type of complaint has been found particularly among women in the French group, as the infibulated women in Switzerland were all first generation immigrants. In particular, the second generation women reported a bad body image and complained of suffering concerning their damaged genitals. Some of them used the term “abnormality” and affirmed that they saw themselves as “different from other women”.
The meanings that the women attach to “reparation” are multidimensional. The management of FGM/C requires a polyvalent and multidisciplinary approach by healthcare services.
The physical dimension is more present in the French group where the surgery is currently practiced and has been reimbursed by public insurance since 2004 . In this context women have easy access to the surgical procedure that is most commonly proposed by healthcare professionals. The women also referred to media as a source of information on the surgical procedure; further studies are recommended to analyse the impact of the media representations of FGM/C and the surgical procedure. The moral dimension of the “reparation” is directly linked with the assumption of sexual health and sexual rights. Sexual rights are evoked in the request for sexual pleasure. Clitoral rehabilitation is considered by some women an individual achievement that eventually helps to achieve and maintain stable relationships . Psychosexual aspects should be investigated further in order to understand specific problems for mixed couples (with a man coming from a different ethnic group where excision is not practiced). Sexual socialization is carried out through several channels, such as sexual education at school, psychological and sexual knowledge circulation through media (documentaries, films, magazines and specific journals, therapeutic works and self-help manuals), pornography, peer-to-peer socialization and discussions. Sexual demands for more pleasure should be interpreted as very closely linked to the social context where women with FGM/C live and may have been socialized since childhood.
Women in in France and in Switzerland are exposed to western culture where the visual aspects of body and genitals are all around . Women with FGM/C, as other women in Western countries, are overexposed to western representations of gender and sexualities . They also are more used to comparing themselves to the majority of the female population, who are non-excised . Excised women give great importance to the discourses and images portrayed in the media, which they equate to the dominant model of what a desirable body (and, by default, the sexual organs) should resemble . The notion of normality or “abnormality” should be understood within this comparison with other French women who represent the dominant model. The representation of the “excised woman” as victims reinforces the social stigma and the perception of abnormality felt by women with FGM/C in France and in Switzerland. Some women report a situation of precariousness, especially in a mixed couple, where the FGM/C is seen as a handicap .
The last dimension relates to ethnic origin and gender. Women express the idea that their bodies do not correspond to the body they want. They compare themselves to their friends who, for the most part, are non-excised women living in France or in Switzerland, and this is particularly true for the 2nd generation women who have grown up in these contexts. These women, born and raised in in France or in Switzerland, most of the time, even do not know about the traditions linked to FGM/C in its original context. The social and cultural representation of FGM/C is for them purely synonymous with crime, bodily harm and loss or reduction of femininity. In the context of diaspora, women are doubly penalised: the practice being performed during childhood is only interpreted by discourses and values condemning the FGM/C as a form of violence. The negative body image affects not only their self-esteem but also their sex life [16,35]. From the ethicized body and gendered sexuality, finally women with FGM/C seem to be prisoners of representations of their body, their genitals and their sexualities.
Specific healthcare services in term of reparative approach allow development of a discussion with women with FGM/C. Medicine is called upon to engage in a dialogue with the patients and their narratives. Reparative approaches may be able to offer more comprehensive healthcare and take an ethical stand when an element of injustice is present.
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