FGM in the time of Ebola—carpe opportunitatem
Authors: Owolabi Bjälkander, Helena Nordenstedt, Kim Brolin, Anna Mia Ekström
Journal: The Lancet Global Health (2016)

Sierra Leone has one of the highest rates of female genital mutilation (FGM) in the world. Before the Ebola virus disease (EVD) outbreak, according to the Sierra Leone Demographic and Health Survey of 2013,1Statistics Sierra Leone (SSL)Ministry of Health and SanitationICF International 2013Sierra Leone Demographic and Health Survey 2013. Statistics Sierra Leone (SSL) and ICF International, Rockville, Maryland, USA2014Google Scholar FGM had been performed on 89·6% of girls and women.FGM is an act performed as part of the initiation ceremony into the Bondo Society. This Society is a traditional, secret women's society led by women called Soweis, who also perform FGM. It is through Bondo membership that girls (traditionally between the ages 15 and 19 years) are recognised as women in their communities.FGM has no health benefits. Negative immediate physical health complications from FGM range from pain, shock, bleeding, and infection, to unintended labia fusion, dermoid cysts, swelling, and oedema.2Hearst AA Molnar AM Female genital cutting: an evidence-based approach to clinical management for the primary care physician.Mayo Clin Proc. 2013; 88: 618-629Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 3Behrendt A The practice of excision in Moyamba and Bombali districts of Sierra Leone: perceptions, attitudes and practices. Plan West Africa Regional Office, Dakar2005Google Scholar, 4El-Defrawi MH Lotfy G Dandash KF Refaat AH Eyada M Female genital mutilation and its psychosexual impact.J Sex Marital Ther. 2001; 27: 465-473Crossref PubMed Scopus (82) Google Scholar Childbirth-related complications include an increased risk of post-partum haemorrhage, caesarean section, and poor perinatal outcomes in women with FGM compared with women without FGM.5Banks E Meirik O et al.WHO Study Group on Female Genital Mutilation and Obstetric OutcomeFemale genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries.Lancet. 2006; 367: 1835-1841Summary Full Text Full Text PDF PubMed Scopus (406) Google Scholar There is also evidence that girls and women with FGM show a significantly higher prevalence of anxiety, somatic disturbance, depression, and post-traumatic stress disorder than do other girls and women.6Vloeberghs E van der Kwaak A Knipscheer J van den Muijsenbergh M Coping and chronic psychosocial consequences of female genital mutilation in the Netherlands.Ethn Health. 2012; 17: 677-695Crossref PubMed Scopus (99) Google Scholar, 7Behrendt A Moritz S Posttraumatic stress disorder and memory problems after female genital mutilation.Am J Psychiatry. 2005; 162: 1000-1002Crossref PubMed Scopus (148) Google ScholarFGM of any type has been recognised as a harmful practice and a fundamental violation of human rights, the rights to the highest attainable standard of health and bodily integrity, among others.In July, 2014, the Ministry of Social Welfare, Gender, and Children's Affairs in Sierra Leone commissioned the development of a national strategy on the reduction of FGM. However, shortly after, the incidence of EVD climbed sharply, and the work on the FGM strategy was deprioritised and halted.However, during the Ebola outbreak, a plethora of other actors—among them both Paramount Chiefs (traditional heads of Chiefdoms who serve to protect the customs and traditions of their people) and some Councils of Soweis—enacted laws and pledges to postpone FGM in order to reduce the risk of EVD transmission. Penalties varied from fines up to 500 000 Leones (about US$110) to public flogging.In April, 2015, at a conference held by the Forum against Harmful Practices, the Political and Public Affairs Minister Honourable Alhaji Ibrahim Kemoh Sesay condemned FGM and called for its eradication. He also estimated that some 70% of daughters and female relatives of members of Parliament were no longer interested in becoming members of the Bondo Society (within which girls aged 15–19 years are formally recognised as women).8Kassa Koroma J Minister calls for abolition of FGM. New Citizen (Freetown).http://www.newctzen.com/index.php/11-news/2514-minister-calls-for-abolition-of-fgmDate: April 17, 2015Google ScholarAs the President of Sierra Leone, His Excellency Dr Ernest Bai Koroma, declared the end of the large outbreak of Ebola in Sierra Leone on Nov 7, 2015, he also stated that "new beginning warrants that traditional practices that have a negative impact on health, and which were discontinued during the outbreak, should not be returned to".9Statement by His Excellency Dr Ernest Bai Koroma, President of the Republic of Sierra Leone at the Declaration of the end of the Ebola outbreak in Sierra Leone. Bintumani Conference Centre, Freetown.http://www.statehouse.gov.sl/index.php/presidents-speeches/1365-statement-by-his-excellency-dr-ernest-bai-koroma-president-of-the-republic-of-sierra-leone-at-the-declaration-of-the-end-of-the-ebola-outbreak-disease-in-sierra-leone-bintumani-conference-centre-freetown-7-novemver-2015-Date: Nov 7, 2015Google ScholarAfter two new EVD cases in January, 2016, Sierra Leone was again declared Ebola free on March 17, 2016. Although byelaws that banned FGM during the epidemic have not yet been lifted officially, there has been a call by one female Paramount Chief to lift the ban and resume FGM in order to "go to the bush to uphold our culture and tradition".10Turay A Sierra Leone News: Paramount Chief calls for lifting of ban on secret societies. Awoko Times (Freetown).http://awoko.org/2016/02/15/sierra-leone-news-paramount-chief-calls-for-lifting-of-ban-on-secret-societies/Date: Feb 15, 2016Google Scholar This statement is a cause for concern.Despite its serious consequences on mortality and the health system, the Ebola outbreak has given us a window of opportunity. Some political and traditional leaders are now speaking about stopping FGM because of its serious consequences on the health of girls, women, and their newborn babies; is this not the time to encourage the total abandonment of the practice?We declare no competing interests. Sierra Leone has one of the highest rates of female genital mutilation (FGM) in the world. Before the Ebola virus disease (EVD) outbreak, according to the Sierra Leone Demographic and Health Survey of 2013,1Statistics Sierra Leone (SSL)Ministry of Health and SanitationICF International 2013Sierra Leone Demographic and Health Survey 2013. Statistics Sierra Leone (SSL) and ICF International, Rockville, Maryland, USA2014Google Scholar FGM had been performed on 89·6% of girls and women. FGM is an act performed as part of the initiation ceremony into the Bondo Society. This Society is a traditional, secret women's society led by women called Soweis, who also perform FGM. It is through Bondo membership that girls (traditionally between the ages 15 and 19 years) are recognised as women in their communities. FGM has no health benefits. Negative immediate physical health complications from FGM range from pain, shock, bleeding, and infection, to unintended labia fusion, dermoid cysts, swelling, and oedema.2Hearst AA Molnar AM Female genital cutting: an evidence-based approach to clinical management for the primary care physician.Mayo Clin Proc. 2013; 88: 618-629Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 3Behrendt A The practice of excision in Moyamba and Bombali districts of Sierra Leone: perceptions, attitudes and practices. Plan West Africa Regional Office, Dakar2005Google Scholar, 4El-Defrawi MH Lotfy G Dandash KF Refaat AH Eyada M Female genital mutilation and its psychosexual impact.J Sex Marital Ther. 2001; 27: 465-473Crossref PubMed Scopus (82) Google Scholar Childbirth-related complications include an increased risk of post-partum haemorrhage, caesarean section, and poor perinatal outcomes in women with FGM compared with women without FGM.5Banks E Meirik O et al.WHO Study Group on Female Genital Mutilation and Obstetric OutcomeFemale genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries.Lancet. 2006; 367: 1835-1841Summary Full Text Full Text PDF PubMed Scopus (406) Google Scholar There is also evidence that girls and women with FGM show a significantly higher prevalence of anxiety, somatic disturbance, depression, and post-traumatic stress disorder than do other girls and women.6Vloeberghs E van der Kwaak A Knipscheer J van den Muijsenbergh M Coping and chronic psychosocial consequences of female genital mutilation in the Netherlands.Ethn Health. 2012; 17: 677-695Crossref PubMed Scopus (99) Google Scholar, 7Behrendt A Moritz S Posttraumatic stress disorder and memory problems after female genital mutilation.Am J Psychiatry. 2005; 162: 1000-1002Crossref PubMed Scopus (148) Google Scholar FGM of any type has been recognised as a harmful practice and a fundamental violation of human rights, the rights to the highest attainable standard of health and bodily integrity, among others. In July, 2014, the Ministry of Social Welfare, Gender, and Children's Affairs in Sierra Leone commissioned the development of a national strategy on the reduction of FGM. However, shortly after, the incidence of EVD climbed sharply, and the work on the FGM strategy was deprioritised and halted. However, during the Ebola outbreak, a plethora of other actors—among them both Paramount Chiefs (traditional heads of Chiefdoms who serve to protect the customs and traditions of their people) and some Councils of Soweis—enacted laws and pledges to postpone FGM in order to reduce the risk of EVD transmission. Penalties varied from fines up to 500 000 Leones (about US$110) to public flogging. In April, 2015, at a conference held by the Forum against Harmful Practices, the Political and Public Affairs Minister Honourable Alhaji Ibrahim Kemoh Sesay condemned FGM and called for its eradication. He also estimated that some 70% of daughters and female relatives of members of Parliament were no longer interested in becoming members of the Bondo Society (within which girls aged 15–19 years are formally recognised as women).8Kassa Koroma J Minister calls for abolition of FGM. New Citizen (Freetown).http://www.newctzen.com/index.php/11-news/2514-minister-calls-for-abolition-of-fgmDate: April 17, 2015Google Scholar As the President of Sierra Leone, His Excellency Dr Ernest Bai Koroma, declared the end of the large outbreak of Ebola in Sierra Leone on Nov 7, 2015, he also stated that "new beginning warrants that traditional practices that have a negative impact on health, and which were discontinued during the outbreak, should not be returned to".9Statement by His Excellency Dr Ernest Bai Koroma, President of the Republic of Sierra Leone at the Declaration of the end of the Ebola outbreak in Sierra Leone. Bintumani Conference Centre, Freetown.http://www.statehouse.gov.sl/index.php/presidents-speeches/1365-statement-by-his-excellency-dr-ernest-bai-koroma-president-of-the-republic-of-sierra-leone-at-the-declaration-of-the-end-of-the-ebola-outbreak-disease-in-sierra-leone-bintumani-conference-centre-freetown-7-novemver-2015-Date: Nov 7, 2015Google Scholar After two new EVD cases in January, 2016, Sierra Leone was again declared Ebola free on March 17, 2016. Although byelaws that banned FGM during the epidemic have not yet been lifted officially, there has been a call by one female Paramount Chief to lift the ban and resume FGM in order to "go to the bush to uphold our culture and tradition".10Turay A Sierra Leone News: Paramount Chief calls for lifting of ban on secret societies. Awoko Times (Freetown).http://awoko.org/2016/02/15/sierra-leone-news-paramount-chief-calls-for-lifting-of-ban-on-secret-societies/Date: Feb 15, 2016Google Scholar This statement is a cause for concern. Despite its serious consequences on mortality and the health system, the Ebola outbreak has given us a window of opportunity. Some political and traditional leaders are now speaking about stopping FGM because of its serious consequences on the health of girls, women, and their newborn babies; is this not the time to encourage the total abandonment of the practice? We declare no competing interests.