(This article is Part 6 of a seven-part series on trauma related to Female Genital Cutting. To read the complete series, click here. These articles should NOT be used in lieu of seeking professional mental health and counseling services when needed.)

By Julia Geynisman-Tan, MD 

Background 

FGM/C has no known health benefits, but does have many immediate and long-term health risks, such as hemorrhage, local infection, tetanus, sepsis, hematometra, dysmenorrhea, dyspareunia, obstructed labor, severe obstetric lacerations, fistulas, and even death. While the psychological, sexual, and obstetric consequences of FGM/C are well-documented (refer to prior posts in this series), there are few studies on the urogynecologic complications of FGM/C. Urogynecology is the field of women’s pelvic floor disorders including urinary and fecal incontinence, dysfunctional urination, genital prolapse, pelvic pain, vaginal scarring, pain with intercourse, constipation and pain with defecation and many other conditions that affect the vagina, the bladder and the rectum. Urogynecologists are surgeons who can both medically manage and surgically correct many of these issues.

FGM/C and Urinary Tract Symptoms

One recent study from Egypt suggested that FGM/C is associated with long-term urinary retention (sensation that your bladder is not emptying all the way), urinary urgency (the need to rush to the bathroom and feeling that you cannot wait when the urge comes on), urinary hesitancy (the feeling that it takes time for the urine stream to start once you are sitting on the toilet) and incontinence (leakage of urine). However, the women enrolled in this study were all presenting for care to a urogynecology clinic and therefore all of them had some urinary complaints so it is difficult to tell from this study what the true prevalence of lower urinary tract symptoms are in the overall FGM/C population.  

Therefore, given the significant number of women with FGM/C in the United States and the paucity of data on the effects of FGM/C on the urinary system, my research team studied this topic ourselves in order to describe the prevalence of lower urinary tract symptoms in women living with FGM/C in the United States. Publication will be available online in December 2018.  

 We enrolled 30 women with an average age of 29 to complete two questionnaires on their bladder symptoms. Women in the study reported being circumcised between age 1 week and 16 years (median = 6 years).

• 40% reported type I

• 23% type II

• 23% type III

• 13% were unsure

Additionally, 50% had had a vaginal delivery; and 33% of these women reported that they tore into their urethra at delivery.

Findings:

A history of urinary tract infections (UTIs) was common in the cohort:

• 46% reported having at least one infection since being cut 

• 26% in the last year

• 10% reported more than 3 UTIs in last year

• 27% voided ≥ 9 times per day (normal is up to 8 times per day)  

• 60% had to wake up at least twice at night to urinate (once, at most, is normal)

Most of the women (73%) reported at least one bothersome urinary symptom, although many were positive for multiple symptoms:

• urinary hesitancy (40%)

• strained urine flow (30%)

• intermittent urine stream (a stream that starts and stops and starts again) (47%) were often reported

• 53% reported urgency urinary incontinence (leakage of urine when they have a strong urge to go to the bathroom)

• 43% reported stress urinary incontinence (leakage of urine with coughing, sneezing, laughing or jumping)

• 63%reported that their urinary symptoms have “moderate” or “quite a bit” of impact on their activities, relationships or feelings

What’s the Connection Between FGM/C and Urinary Symptoms?

Urinary symptoms like the ones described above can be the result of a number of factors. Risk factors for urinary urgency and frequency, incontinence, and strained urine flow include pregnancy and childbirth, severe perineal tears in labor, obesity, diabetes, smoking, genital prolapse and menopause.

However, given the average age of women in our sample and the fact that only half of them had ever had a vaginal birth, the rate of bothersome urinary symptoms are significantly higher than has been previously reported. FGM/C may be a separate risk factor for these symptoms. Interestingly, the prevalence of urinary tract symptoms in our patients closely resembled that of a cohort of healthy young Nigerian women aged 18-30, in which the researchers reported a prevalence of lower urinary tract symptoms of 55% with 15% reporting urinary incontinence and 14% reporting voiding symptoms. The authors do not mention the presence of FGM/C in their study population but the published prevalence of FGM/C in Nigeria is 41%, with some communities reporting rates of 76%. Therefore, it is likely that many of the survey respondents had experienced FGM/C, thereby increasing the prevalence of lower urinary tract symptoms in their cohort. In the study of women in Egypt referenced above, those with FGM/C were two to four times more likely to report urinary symptoms compared to women without FGM/C.

The connection between FGM/C and urinary symptoms can be understood from the literature on childhood sexual assault and urinary symptoms. Most women who experience FGM/C recall fear, pain, and helplessness. Like sexual assault, FGM/C is known to cause post-traumatic stress disorder, somatization, depression, and anxiety. These psychological effects manifest as somatic symptoms. In studies of children not exposed to sexual abuse, the rates of urinary symptoms range from 2-9%. In comparison, children who have experienced sexual assault have a 13-18% prevalence of enuresis (bedwetting) and 38% prevalence of dysuria (pain with urination). The traumatic imprinting acquired in childhood persists into adult years. In a study of adult women with overactive bladder, 30% had experienced childhood trauma, compared to 6% of controls without an overactive bladder. There is a neurobiological basis for this imprinting. Studies in animal models show that stress and anxiety at a young age has a direct chemical effect on the voiding reflex and can cause an increase in pain receptors in the bladder. Additionally, the impact of sexual trauma on pelvic floor musculature has been well described. Women who experience genital trauma often respond with an involuntary contraction of the pelvic floor, which can develop into non-relaxing pelvic floor dysfunction and subsequent urinary hesitancy, strained flow, retention, bladder pain and overflow incontinence.

These Conditions are Treatable

There are treatments for all of the conditions. Urinary hesitancy, strained flow, bladder pain, and urgency are often treated with pelvic floor muscle therapy. That is because many of these symptoms come from an unconscious, constant clenching of the pelvic floor muscles, which then prevents them from using their full range of motion and pinches off the nerves running through the muscles. Pelvic floor therapy focused on lengthening and stretching these muscles can completely change the way that you urinate and the sensation of pain in the pelvis. This kind of physical therapy is done by all female providers in a private room. The therapy consists of a combination of external and internal work on all of the muscles of your core and pelvic floor to release trigger points of tension and teach you how to relax and lengthen these muscles. Sometimes the therapists use biofeedback devices in the vagina to help you to recognize certain muscles groups. The sessions are usually one hour long and last for 6-12 visits. You can obtain a referral to a pelvic floor physical therapist from your local urogynecologist.

If you have urinary leakage throughout the day or nighttime, this can also be treated. Your urogynecologist can help differentiate whether you have stress urinary incontinence (leakage with coughing, laughing, exercise, lifting) or urgency urinary incontinence (leakage that follows the urge to go to the bathroom or sometimes sporadic leakage without any urge). These types of incontinence are treated differently but both can be treated with a combination of medicine, office procedures or surgical treatments. To find a urogynecologist in the Unit, you can go to the website of the American Urogynecologic Society and click on patient services.

About Julia Geynisman-Tan

Julia is a Female Pelvic Medicine and Reconstructive Surgeon in the Department of Obstetrics and Gynecology at Northwestern. During her residency at New York Presbyterian – Weill Cornell, she founded the Survivor Clinic of New York City, a dedicated clinic for women who had experienced sexual violence, including trafficking, female genital mutilation, and torture in war. Now in Chicago, Dr. Geynisman-Tan has founded the Northwestern ERASE Clinic for survivors of human trafficking and is an asylum evaluator for Physicians for Human Rights. She is currently a co-chair of the American Women’s Medical Association Physicians Against Trafficking of Humans Committee, on the board of the America Hospital Association’s Human Trafficking Consortium and serves on the Cook County Human Trafficking Task Force.

By Debangana Chatterjee 

Though often being referred to as an Islamic practice, Female Genital Cutting (FGC) precedes both Islam and Christianity. It is believed to have originated in the Pharaonic era of Egypt. Elizabeth Boyle, author of Female Genital Cutting: Cultural Conflict in the Global Community, mentions in the book that before the advent of Islam, Egyptians, who valued FGC (particularly infibulation), introduced a strong slave system and expanded it towards the adjacent geographic region. At the onset of Islam in the Egyptian controlled region, Islam asserted a stringent prohibition towards enslaving other Muslims. Hence, non-Muslim were continued to be used as slaves, and since FGC was done to these non-Muslim women slaves to increase their worth and value as slaves, FGC was by extension spread to other parts of Africa by the slave traders. This remains one of the driving factors behind the spread of FGC in Africa simultaneous to the rise of Islam.

Despite FGC predating Islam, the myth of it being an Islamic practice persists due to the impressions of virginity and purity remaining closely associated with the religion’s values. There are ample reasons to challenge the unnecessary association of the practice with the Islamic culture. First, FGC was common among the Egyptian Coptic Christians and a number of Tanzanian Christian communities. In fact, FGC was also reportedly performed on Western women in the 1950s as a cure to nymphomania and depression according to L. Amede Obiora.

Secondly, the practice is rife only among a limited number of Islamic practitioners of the world. Islam is the world’s second largest religion with approximately 1.6 billion followers of the religion consisting of 23.2 percent of the world population. On the other hand, there are around 200 million reported cases of FGC worldwide which includes non-Islamic people as well. Even if one takes these numbers as absolute, merely 12 percent (approx) of the entire Islamic population is affected by the practice. Thus, FGC does not necessarily qualify as an Islamic practice, considering most of the followers of the religion either nullify FGC or even remain oblivious to it. Third: the Holy Quran altogether stands in opposition to inflicting harm; going by that logic Islam cannot be supportive of FGC inflicting mental/physical harm of any sort onto women/girls. Despite the Prophet being explicit about sunna (tradition) on male genitals, FGC’s existence within Islam remains debatable.

In many countries, Islamic traditions often remain debatable, including discussions on FGC. In the documentary The Cutting Tradition, an imam from the Harar region of Ethiopia is heard explaining how it already existed among various communities and the Prophet merely advised a sunna way of cutting where only the nicking of the clitoral prepuce is permitted. In the same documentary the Grand Mofti of Egypt, Fadilet Al-Mofti Ali Gomma repudiates any religious basis for FGM/C, though in 1994 a religious decree was issued in the country in favour of the practice stating it as an honourable deed for women. In fact, the decree, issued by one of Egypt’s prominent clerics Sheikh Gad el-Haqq, admittedly mentioned that FGC is not obligatory in Islam but should be followed due to the traditional rituals attached to it.

Even in the Afar region of Ethiopia, religious leaders are seen invoking Islamic scripture and text to counter continuation of FGC among practicing community members.

The practice came to South-East Asia in the 13th century, due to the advent of Islam in the region after the change in regime. The Shafi school of Sunni Islam in Indonesia and Malaysia considers FGC an Islamic practice, yet they are culturally influenced by the region where Yemen and Oman are situated, countries that have considerable FGC prevalence.

At a time in the world when right-wing politics riles up with growing Islamophobia, it is important not to straightjacket Islam in order to avoid its unnecessary vilification and mindless demonization. Islam, as it grew, got entangled with cultural traditions in such a manner that it often looks inseparable. But a close and nuanced study of the matter opens it up for further scrutiny and leaves room for potential dialogic engagement with the communities practicing female genital cutting so that in time these communities will come to abandon it.

 Read Part 1 – What Islam says about Female Genital Cutting and how far are these texts invincible?

More about Debangana

 Debangana is a doctoral scholar at the Centre for International Politics Organisation and  Disarmament (CIPOD), Jawaharlal Nehru University. Through her research, she is trying to locate the existing Indian discourse surrounding the practices of FGM/C and Hijab into the frame of international politics. If you would like to connect with Debangana, you can reach her at This email address is being protected from spambots. You need JavaScript enabled to view it..

(Please note that a version of this article appears on LankaWeb.com. It has been republished here with permission from the author.)

By Fatima Yasmin  

Country: Sri Lanka

Muslim religious organisations in Sri Lanka have called on the government to medicalise female circumcision to ensure the procedure is done under hygienic conditions. In their submission before the Parliamentary Committee on Women and Gender early in September, the Muslim groups stated that the Muslim community was very concerned about moves to ban the procedure on the grounds that it was Female Genital Mutilation (FGM).  

Spokeswoman Noor Hazeema Haris has reportedly said that although Muslims wholeheartedly have supported the abolition of traditional practices harmful to women and children such as Female Genital Mutilation, the Islamic practice of female circumcision was very different.  

She pointed out that the distinction is that female circumcision as practiced by Muslims in Sri Lanka, was a minor procedure, in which only the prepuce or hood of the clitoris was removed.

“It is something that is arranged and done by women. Those who say this is male oppression against women are mistaken. It is we who do it just like our mothers and grandmothers and countless generations of our women have done. We continue to practice it because we know it benefits us. Even educated Muslim women support it wholeheartedly,” she said. “If medical complications have arisen among some women circumcised by Osthamamis (traditional female circumcisors without medical training) as alleged by women’s rights groups, it is all the more reason to medicalise the procedure instead of prohibiting it, which will only drive the procedure underground and put girls and women at unnecessary risk.”

The move is a very dangerous one since it could lead to greater acceptability of FGM. There have been many complaints raised against traditional practitioners including the use of unsterile instruments and harming the clitoris in some cases. However, I believe the solution is to ban it altogether rather than medicalising it.

But analysts warn this could lead to an uproar from religious parties and have political implications since parties that come out against FGM risk losing a large and influential Muslim vote bank. The All Ceylon Jamiyyathul Ulama, an organization of religious scholars in the country issued a fatwa in 2008 stating that female circumcision was obligatory, and was among the parties that made representations to medicalise the practice early in September.

It is also a matter of concern to women’s rights groups that the said Parliamentary committee agreed to accommodate the representations and requested that medical evidence is submitted to prove that female circumcision of the type prescribed in Islam, as stated by these religious groups, causes no harm and benefits women.

A female doctor who performed the procedure before a health ministry circular prohibiting medical professionals from performing it came into effect in the country in October, and whose name has been withheld here by her request, said that she welcomed the move to medicalise it:

“I performed about 25 circumcisions a day in a private clinic, mostly infants. But there were women, too. Some were newly married and wanted to be circumcised at their husbands’ request. All I do is remove a little bit of skin covering the clitoris. I use a very fine instrument for the babies. It takes only a few minutes. In the case of adults, I inject an anesthetic before proceeding to circumcise them. My patients tell me it’s only the injection that hurts a bit and that after that they don’t feel a thing. It’s sore for a few days but heals fast. There is a huge demand for this service. It’s a shame that it’s now going back into the hands of untrained women who have no proper medical knowledge and who use unsterilized instruments for the purpose.”

A young mother who had her infant daughter cut by a traditional practitioner also agreed.

“Doctors refuse to do this now, and I was forced to get it done by an Osthamami. She took out a blade which looked as if it had been used many times and made a cut to my daughter’s genitals. Some blood came out. I could not bear to look. Later I checked it and noticed a cut had been made in the skin over the clitoris but the foreskin had not been removed. This is an improper circumcision according to my sister who is an Aalimah (religious scholar) and so I will have to get her circumcised again. Why are these so-called women’s groups against doctors doing it? We will practice it whether they ban it or not.”

However, a member of a prominent women’s organization said that prohibiting the practice is the right thing to do.

“FGM has been condemned as a violation of the rights of women and girl children by the World Health Organisation. WHO makes no distinction between FGM and the type of circumcision practiced here. It’s all the same. How can you cut these girls and call it a religious obligation? I understand there is a strong religious argument for the practice, but we cannot let religion affect the health of girls and women.”

And so the debate goes on – to ban or medicalise. One thing is for sure. It won’t be easy. Not only does the religious establishment in Sri Lanka, unfortunately, support the practice, but many local women are for continuing it, meaning the government and activists working to end FGM will face many challenges ahead before FGM can be abandoned in Sri Lanka.

By: Koen Van den Brande
Age: 56

Country: India

I rarely speak of the devil.

In Germany they have a saying:

Du sollst den Teufel nicht an die Wand mahlen
Literally this translates to ‘Don’t paint a picture of the devil on the wall’.

Loosely translated it means that you should not invite evil by talking about it.

But maybe there are times we have a duty to alert others to the devil’s work.

What I mean by that is not that anyone in particular is a devil but rather that maybe at times the devil has a hand in misleading people. 

My efforts to get to the bottom of the origins of the practice of ‘khatna’ – what the rest of the world calls ‘Female Genital Mutilation’ (FGM) – in the Suleimani community, recently led me to the inevitable conclusion that the devil has had a hand in twisting the words of the Prophet PBUH, to mean the opposite of what He was saying.

My attention was drawn to some research carried out by learned members of the Muslim community. Let me present the facts to you so that you may come to your own conclusion.

Early on in my own research I came across a Hadith – a reported saying of the Prophet – which was being quoted as evidence of tacit approval of this ancient practice, which predated Islam and may have been initiated in the distant past to subdue the sexual urges of female slaves.

My discussions with members of the Suleimani community had made it clear that the Daim-ul-Islam is the rulebook to which many show an unquestioning allegiance.

Of course such blind faith can have dire consequences. The Daim-ul-Islam does indeed refer to the Hadith in question. Following is an extract from a paper published on www.alislam.org, with the title ‘Female circumcision and its standing in Islamic law’.

But it turns out this is not the full Hadith.

 In full, the Hadith seems to leave little doubt as to where the Prophet stood on this matter. The authors of the report quote from Al-Kafi, a respected Shiite book of traditions.

Was the Prophet endorsing, encouraging or even mandating that women should be cut?

Or was he signaling his disapproval and in the face of a long-established tradition, trying to limit the harm done to women? Given what he says, is it correct to claim, as some do, that he should have forbidden it, if he really felt it was wrong?   

I will leave it to you to draw your own conclusion.

For me these words of Mohammed, now in full view, are consistent with other issues where he championed the rights of women in the face of a culture which at that time saw no reason to do so.

Who decided to shorten the hadith and to what end? And at which point did a woman who ‘used to circumcise women slaves’ become a woman who ‘used to circumcise girls’? There is a substantive difference is there not?

Just as with the modern day suggestion that Mohammed condoned wife-beating, when in fact he counseled restraint and suggested several alternative ways of resolving marital disputes or the insistence by some on the validity of ‘triple talaq’ divorce, where in fact careful mediation over a period of time is prescribed, one can only conclude that the devil himself has repeatedly sought to undermine the Prophet’s cause as champion of the rights of women!

Today we call this ‘fake news’ and we are learning day by day, how it is used to mislead those who believe without questioning.  

Witness how the young parents of our community are systematically fed disinformation, building on that same principle of blind faith. But blind faith in whom?

I quote from the website www.islamqa.com.

Search for the term ‘khatna’ and the following question is addressed, among others:

This is how the scene is set:

I wonder what a properly qualified medical practitioner would make of some of the advice given.

Need I say more ?

How do we tackle such blatant attempts at misleading parents of young girls?

Surely the best strategy must be to focus on facts and truth. So I am attempting to find a consensus across the Suleimani community around the following statement.

“I as a member of the Suleimani Jamaat, in the interest of young parents and their girls, want to reflect what I believe to be the truth about the practice of khatna. 

Fact is …

1. It is a tradition which predates Islam 
2. It is not mentioned in the Quran at all 
3. It is not practiced by all muslims 
4. It has been declared a crime in several Muslim majority countries 
5. It is considered a health hazard by the World Health Organization
6. It is considered a crime against a child by the United Nations

Truth is, in my humble opinion, that the Prophet Mohammed PBUH frowned upon this practice and sought to prevent harm from being done to women.

I believe that these facts should be endorsed by our leadership and communicated to all of the Jamaat ‘s young parents. 

The Daim-ul-islam states that ‘khatna’ is not obligatory and that it should not be performed before a girl is 7-years-old. 

I believe that it would be in line with this rule to recommend to parents that any decision to proceed with this practice should be postponed until the age of consent. 

And in line with the Prophet’s guidance, at a time when it was a more common practice, I believe that when and if it is performed, it must be done symbolically only and cause no harm.”

I hope you can join the effort by endorsing this statement.

And if you cannot, I invite you to propose an alternative.

At least let’s start by banning the use of http://www.isllamqa.com

Let us work together to undo the work of the devil.  

 This blog is the third in a three-part series that describes the practice of FGC within the Suleimani Bohra community. Read the others here and here.

On October 19 in Oakland, California, Sahiyo, in collaboration with StoryCenter, Asian Women’s Shelter, Asian Pacific Institute on Gender-Based Violence will host a screening of Sahiyo Stories with a behind the scenes short film documenting the women’s experiences in creating their digital stories, followed by a panel discussion on FGC. 

To RSVP for the event, visit http://bit.ly/SahiyoStoriesOct

As a reminder, the project brought together nine women from across the United States to create personalized digital stories that narrate the experience of undergoing female genital mutilation/cutting (FGM/C) and/or the experience of their advocacy work to end this form of gender violence. You can watch all these brave women’s stories by visiting the Sahiyo Stories YouTube Playlist.

If you’re interested in learning more about the project or hosting a screening of Sahiyo Stories, contact This email address is being protected from spambots. You need JavaScript enabled to view it.