Hepatitis B and Female Genital Mutilation

Hepatitis B and C and Female Genital Mutilation

FGM practising nations have shown some of the highest levels of HBV infection globally. The FGM victims are testing across the world at 5 to 10% having lasting incurable HBV infections and 50 to 95% having had the infection at some point. It is extremely important people realise HBV is more likely to kill and 100 times more infectious than HIV. Victims are 1% dying by 20 and up to 20% dying by 50. One drop of HBV blood on a ritual razor can infect 10 girls a day for month. For under fives with childish immunity systems this equates to one cutter being quite able to incurably HBV infect 150 girls a month. 

Burkina Faso has led the way regarding both policy and successful elimination for the whole African Continent since 1990. Understanding their 25 year usage of each of anti FGM’s 4 wheels is crucial as all 4 have created an incredible drop from 76% practising to just 9% supporting FGM in Burkina Faso.

 The 4 Wheels That Stop FGM rapidly
1. Education of health and birth consequences
2. Education of human rights 
3. Laws 
4. Penalties

The 14 FGM Health Complications Every Survivor should be educated in when having their babies 

 It is crucial to get FGM mums to relate their illnesses to FGM. The highest maternal and infant mortality rates are in FGM-practicing regions.17 One quarter of women in Central African Republic and 1/5 of women in Eritrea reported FGM-related complications.20 Where medical facilities are ill-equipped, emergencies arising from the practice cannot be treated. Thus, a child who develops uncontrolled bleeding or infection after FGM may die within hours.21 

1. Intense pain and/or haemorrhage that can lead to shock during and after the procedure. A Sierra Leone study found that nearly 97 percent of the 269 women interviewed experienced intense pain during and after FGM, and more than 13 percent went into shock.22 
2. Haemorrhage can also lead to anaemia. 
3. Wound infection, including tetanus. A survey in Sierra Leone showed that of 100 girls who had FGM, 1 died and 12 required hospitalization, 10 suffered from bleeding and 5 from tetanus.24 Tetanus is fatal in 50% of cases.25 
4. Damage to adjoining organs from the use of blunt instruments by unskilled operators. According to a 1993 nationwide study in the Sudan, this occurs approximately 0.3 percent of the time. 26 
5. Urine retention from swelling and/or blockage of the urethra. 

Long-Term Reproductive and Health Complications
6. FGM survivors are 5-10% HBV infected – often the same unsterilized instrument is used on several girls at a time, increasing the spreading HBV or another communicable disease.35 
7. Problem menses. In a study, 55.4% women in Somalia, reported abnormal menstruation.27 
8. Recurrent urinary tract infections. A 1983 study in the Sudan revealed that 16.4 percent of women who had the operation experienced recurrent urinary tract infections.28 
9. Abscesses, dermoid cysts, and keloid scars (hardening of the scars). 
10. Increased risk of maternal and child morbidity. Women who have undergone FGM are twice as likely to die during childbirth and are more likely to give birth to a stillborn child than other women.29 Among 33 infibulated mothers studied all required extensive episiotomies during childbirth, second-stage labour was 5 times longer than normal, 5 of their babies died, and 21 suffered oxygen deprivation because of the long, obstructed labor.31 
11. Infertility. In the Sudan, 20-25% of female infertility has been linked to FGM complications.32 
12. The psychological effects of FGM ranging from anxiety to severe depression and psychosomatic illnesses.33 Many children exhibit behavioural changes after FGM, but problems may not be evident until the child reaches adulthood.34 
13. Complications Often Need Expensive and Ongoing Medical Attention. According to a study conducted in a small rural village in Sierra Leone, 83 percent of women who had undergone FGM would require medical attention resulting from the procedure. 36 According to a survey of 55 health providers in the Nyamira District of Kenya, almost half encountered women with chronic FGM-related complications. 
14. FGM often Impedes Women's Sexuality FGM destroys much or all of the vulval nerve endings, delaying arousal or impairing orgasm.38 In a 1993 Sudanese study, 5.5 percent of women interviewed experienced painful intercourse while 9.3 percent of them reported having difficult or impossible penetration.39 Of 1,545 Sudanese women who had undergone the operation interviewed. Fifty percent of them said that they did not enjoy sex at all and only accepted it as a duty.40 
At the Hepatitis B Trust we have taken helpline phone calls from several hundred Female Genital Mutilation (FGM) survivors with cleared or lasting Hepatitis B infections.  We also note UK Somalis catching Hepatitis B at a 1 in 50 a year rate before primary school in Liverpool see, 
There is a real need to explain the Hepatitis B Infection levels and health issues related to FGM.  In one to one and group meetings when we do we find the practice is eradicated every time.  Over the last decade, when we talk to Somali and other FGM afflicted nationalities at awareness events, they often even remember the kids going yellow after the cutting with their HBV. They call it “Agbarshoe” in Somali, a common 8 week after effect of FGM, we noted the same phenomena in Kurdish is called Zerwreck. Further, the Cutters are estimated to be as infected as Nigerian Surgeons (25% hbv positive), and are known to bully or frighten people into performing FGM, we have heard of it being done on English girls of African origin to pay for other debts run up by relatives. 

Point being every HBV positive mother we have spoken to understands the 14 health issues caused by FGM rapidly as they have direct experience of many as victims themselves usually. As the chronic or cleared HBV infections emerge via testing in the family the FGM problem is guaranteed over for good and the HBV problem is the legacy they have to try to live through. Most extended African families in high FGM cut nations have several infections and even deaths due to HBV, indeed many have multiple deaths now, with HBV surging past malaria as a killer in Africa.
We need to be aware of this simple fact (FGM victim’s test 5% positive) to end FGM in our community, as is happening in many African states for decades.  We aggressively test all extended FGM families and you will be amazed at the 50 to 80% catch HBV and 4 to 10% carry HBV ratios! We need to point out these terrifying infection, death and illness realities, when being cut by a cutter who is often infectious and has no notion how to avoid an infection. 

It is common on our helpline to get 3 generations of an African family weeping with guilt about FGM as they deal with the cost health wise. We express in family counselling a less guilt more learning approach, pointing out even western scientists were all doing many millions of infectious hepatitis operations and injections until recently and only understood these bugs in the 80's after 1 in 4 humans had caught them. 

Mothers trying to survive HBV do not play Russian roulette with their children catching it from FGM.

We note educated families get very busy testing and warning others, the key point they share is FGM is unhealthy or even deadly done by amateurs...and there are no hep safe hospitals in Africa that cut .....and ours won’t, period. Cleanest would be Egypt with 100,000 HCV infections annually. Spiritually we list Quran verses stating that FGM is haram or against Gods wish. We find the imams and moulanas can respond extremely well to explanation about female circumcision being medically proven to hugely harm, indeed unlike UK police, educators or doctors who ask for 20 years to end the practice via reportage, they can do it with a single order and so can our health service by publicising the terrible health consequences to the victims. 

FGM is never safe from a serious HBV or HCV risk

One caller asked "What if they unwrap the razor in front of you?" Regarding the use of a new double sided razor, it’s often almost a guarantee of wounds to the cutter and onward infection. In such agony without sedation every cut on the small girl produces reflex muscle agony contractions that struggle and wound the victim and the cutting party further. Any infection control or even control of cut angle and depth is clinically impossible. Far more concerning is the fact that repeatedly we have reports of cutting parties in Africa (and also more often UK based lately) where the cutter is progressing from victim to victim covered in HBV fomites (micro blood traces) from hacking away. Rather like tattooists many imagine a clean needle makes up for the fact that they themselves, the environs and every single thing in it is not bleached after the last cut or tattoo. 

Many callers reported huge bloodspills on everything from each cut child, some venues where so bloody it would be quite impossible to enter and sit with a flowing wound and not get infected. A number of times we have heard of the boys being lined up and cut with one razor in one go. The removal of FGM stitches and follow up is another risk whilst the whole procedure places the child at still further risks from the African cutters themselves, who all still transmit hbv along many procedures. 

Another upsetting thing for victims is of course explaining incurable hepatitis b to them, many call after being diagnosed with their testing at first pregnancy stage or at university age when tested for work purposes, and explaining the health damages and Hepatitis B is very hard at such a time. I mean on top of being butchered they were given an incurable bug 100 times as infectious as HIV has been said by one. Many nations of origin understood the crucial infection rates among African children decades ago. With our UK NHS Sentinel Testing suggesting 45,000 children with cHBV in the UK from all causes, (children in UK Hospitals have tested 0.8% HBV positive for years) I would expect right now 5,000 chronically infected FGM child survivors to be in our midst and 10 times that number with signs of past infection or liver damage. 

FGM survivor callers sometimes say they felt alone and betrayed ever since with flashbacks and unreal feelings back at school. A UK nurse cut at 13 in 2007 said she had no one to talk to in the NHS hospital she ended up in, that no police or independent people met her. She felt the whole world just watched. She remembered a NHS staffer asking "Do you think what has happened is wrong?" and wanting to slice her up there and then and ask her the question! 

Can more be done before the cut to stop the UK's FGM and girls catching HBV? 

Yes. Burkina Faso and lead African nations have halved or 95% ended their problems since 1995 with health educations, hotlines and penalties for failure parents.

In closing we want the facts about HBV to be mentioned always alongside FGM inseparably. If it’s 10 times more likely to give a girl chronic HBV than an adult injecting heroin drugs and we have to tell people. Basically we have a duty to warn FGM survivors you need testing and to teach the 14 huge illnesses associated with FGM. 

We do find memorising FGM’s 14 morbidities helps communities end the practice fastest.  What parent on Earth offers their daughter something 100 times more infectious than sleeping with HIV? Only the ones that have not been warned yet, over a decade of counselling, we have often found it is that simple. Bottom line health care education is ending the practice globally, if mothers and communities are never explained why it is a healthcare crime, they will carry on with thinking it is diverse and multicultural, as some still do.     
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