Female Genital Mutilation (FGM)

The staff and Management of the Edna Adan Maternity and Teaching Hospital wish to express appreciation for the financial support received fromNorwegian Peoples Aid that provided part of the funds to undertake this survey.

Sincere thanks and appreciation is expressed to the staff and students of the Edna Adan Maternity and Teaching Hospital who collected the data and recorded their findings on the Prenatal Charts following the physical examinations of the women attending the Prenatal Clinic.

Sincere appreciation is expressed to the Midwives and Doctors who provided Prenatal Care to the women and who supervised the students during their rotation in the department.

Sincere appreciation is expressed to the Administrative staff of the Hospital who undertook the tedious task of typing the data that had been collected by the midwives and student nurses and which had been recorded in the individual patient charts.

Sincere thanks goes also to Amal Ahmed Ali who provided much appreciated support in editing the draft document.

The tabulation and analysis of the data collected could not have been carried out without the valuable assistance of Dr. Emma Watkins of Kings College Hospital, Denmark Hill, London, to whom sincere thanks is being expressed.

What is Female Genital Mutilation?

According to the definition of the World Health Organization (WHO), Female Genital Mutilation FGM comprises all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons and does not include medically prescribed surgery or that which is performed for sex change reasons. It is practiced in more than 20 countries throughout Africa, the Middle East and Asia, and within immigrant populations throughout the world with prevalence rates ranging from 5-99%. Its practice can be found among all religious, ethnic and cultural groups and across all socioeconomic classes. It is estimated that up to 130 million women and girls have already been subjected to some form of FGM and 2 million more are expected to experience it each year.

Female Genital Mutilation (FGM), also known as Female Circumcision (FC), or Female Genital Cutting (FGC), is a universal practice that results in many health-related and life threatening complications. It also has other physical and psychological effects that do great harm to the wellbeing of women and children who have had it performed on them.

In the countries where most or a large number of women have been mutilated, the medical complications that result from these practices place a heavy burden on the health services of these countries.

Classification

Procedures vary throughout the world but the WHO classifies FGM2 into four types as follows:

Type 1: Excision of the prepuce with or without excision of the clitoris.

Type 2: Excision of the clitoris with partial or total excision of the labia minora.

Type 3: Excision of part or all of the external genitalia and stitching together of the exposed walls of the labia majora, leaving only a small hole (typically less than 5cm) to permit the passage of urine and vaginal secretions. This hole may need extending at the time of the menarche and often before first intercourse.

Type 4: Unclassified, covers any other damage to the female genitalia including pricking, piercing, burning, cutting or introduction of corrosive substances.

Global Prevalence

Female genital mutilation is a widespread practice that is carried out on young girls between the ages of 5 and 10 years, and in some countries on grown women as well. Unlike male circumcision, female circumcision is not a Religious obligation required by Islam, Christianity, or any of the other known religions; The practice is nevertheless a cultural tradition. It is practiced mainly in Africa and in some Asian countries. At one time it is said to have even existed in Europe before it was abolished in that continent some centuries ago.

In recent years because of immigration and population movements, the practice is emerging among refugee populations in Europe and North America where the medical and obstetrical complications that mutilated women and girls are seeking treatment for is causing a lot of concern among health-care providers in Western countries. This concern is expressed through the constant attention FGM receives from international health and human rights organizations as well as from the world media.

Studies of FGM Prevalence

Prior to this present study that is being reported on, there had been very few studies conducted in the past, or studies had been on a small number of women.

Some of the most accurate early data on FGM comes from Fran Hosken3 who in 1982 compiled statistics from her many years of studying FGM in Africa. Between 1995 and 2002 the Demographics and Health Surveys published data compiled by questionnaire from 16 countries, but Somaliland and Somalia were not included. Countries that have had repeated data collected have shown small declines in prevalence and a trend to less severe forms of mutilation4. There are a number of published studies from African countries, (not including Somaliland), in particular Nigeria, which have estimated FGM prevalence, but most have involved small numbers and have only been carried out over short periods

In 1998 a national survey by the Ministry of Health in Somalia stated a 96% prevalence rate. In 1999 Care International studied Somaliland and stated that it was universal, with 91% undergoing the most severe form, Type 3. A Swedish study published in 1991 questioned 290 Somali women living in Sweden and found that 100% had FGM, with 88% being Type 3 despite a relatively high socio-economic level, and the majority was willing to perform FGM on their daughters due to religious reasons. A recent study by the WHO and UNICEF looking for the first time, into HIV prevalence also asked women about their FGM status. The study included 769 women and found that 98% had undergone Type 3 circumcision.

World Wide Opinions about FGM

The United Nations and other humanitarian organizations consider FGM a violation of human rights. As early as 1979 the WHO recommended, at an international conference, that the practice should be eradicated and in 1993 the World Health Assembly called for abolition of the practice. Consequently, most countries have strict laws forbidding the practice.

FGM In Asia

Female Genital Mutilation is occasionally reported to be practiced by a limited few in Oman; Saudi Arabia; United Arab Emirates; Yemen; and by even fewer in certain communities in Indonesia; Malaysia; India and Pakistan.

FGM In Africa

Female Genital Mutilation is reported to exist in many African countries, in some it is performed on all or most women while in others it may be performed only on some women belonging to certain ethnic groups.

The countries where FGM is reported to be practiced with varying applications of Types and different prevalence rates are:
Benin; Burkina Faso; Cameroon; Central African Republic; Chad, Democratic Republic of the Congo, Djibouti, Egypt, Eritrea, Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, Somalia, Somaliland, Sudan, Tanzania, Togo, Uganda.

FGM in Somaliland

It has long been accepted that FGM is ubiquitous in Somaliland but accurate data has been lacking. Anecdotal evidence suggests that the procedure was commonly performed on girls between the ages of 4 and 11 and that 95–100% of women had undergone the procedure, the majority of whom having been subjected to the most severe form of mutilation. The study included in this present report shows that 97 % of the Somaliland women receiving antenatal care at Edna Adan Hospital have undergone FGM. In Somaliland the women refer to their procedure by two names, the Sunna and the Pharaonic. The Sunna correlates with Type 1 and 2 but also involves stitching of the anterior part of the genitalia to varying extent. The Pharaonic correlates with Type 3.

Many successful awareness campaigns have been run in Somaliland since 1997 and as a result more Somalilanders are willing to openly discuss the topic of FGM and are becoming increasingly concerned about the health risks associated with the procedure.

The Procedure

The day of the FGM is considered an important event but it is kept secret from the pre-menarche child, and then sprung upon her once the necessary preparations have been made. Senior female members of the community, relatives, traditional birth attendants (TBA’s) or occasionally healthcare workers may be called upon to carry out the procedure.

No anesthesia is used while this very sensitive part of the female body is being brutally cut and manipulated, except when the operation is being performed by a health professional who has access to anesthetics and who the required knowledge in their use.

The age at which female genital mutilation is performed varies from country to country and according to the type of mutilation being done. The SUNNA is generally the type that is performed at a very young age and may be carried out soon after birth, during the first week of life or at any time before the Menarche. In the case of EXCICION and INFIBULATION when more tissues are to be removed which entail more manipulations, the child is allowed to grow older so that the tissues intended for excision are also given a chance to grow. This gives the operator a better pinch or grip. According to the findings of our survey, it was found that the usual age when Excision and Infibulations are performed is between seven and nine years of age.

Instruments and Methods

The Instruments

• Any sharp cutting instrument such as a knife, broken glass, razor blade will do, or the operator may have somehow acquired medical instruments like a scalpel, forceps or scissors.
• The instruments may be new or may have already been used for other purposes and/or on other persons.
• Sterilization is seldom known nor performed by these traditional operators.

The Sutures

• Regular surgical Catgut, Silk or Cotton thread.
• Domestic sewing thread.
• Vegetable or nylon fiber pre-selected by the operator.

The Needles

• Regular surgical suturing needles
• (round bodied or sharp and any size)
• Domestic sewing needle.

Approximating the Wound

In some cases, instead of suturing together the raw edges of the wound, these are held together with thorns that are inserted on opposite sides of the wound and then laced together with thread and left in place for seven days or until the tissues of the wound have had time to fuse together. This type of infibulation is often practiced by nomads and agro–pastoralists.

Condition of Hands

• No gloves are worn during the operation.
• Hands may or may not be washed and in any case wet fingers are slippery and should the operator have difficulty in pinching the skin being removed, it is not unlikely for the operator to wipe his/her hands on the thighs of the child or even on the sand on the ground in order to dry them and thus improve dexterity!
• The operator allows his/her nails to grow as they are used as pincers during operations. Rings, amulets and other hand ornaments are rarely removed, as these items are not recognized by the traditional healer as likely sources of contamination.

Clothes and Bedding

Since bleeding will occur and since there will be some secretions for some days, the family usually finds an old mat or floor covering that can later be discarded.

Sometimes sand is placed on the mat under the buttocks of the child in order to absorb blood and other secretions.

In the case of more affluent or educated families, they may be more likely to be aware of the risks of infection and usually such families would have clean sheets and also gauze pads to absorb any blood or secretions from the wound.

The Operation Itself

The child is made to squat on a stool or mat facing the operator at a convenient height that offers the operator a good view of the parts to be handled. This is important for the operator is often an elderly person whose sight may be impaired and who may find bending over difficult.

Understandably, it is vital for the child to be held as still as possible in order to avoid inflicting cuts other than those intentionally being carried out for the purpose of Infibulation. For this, adult helpers grab and pull apart the legs of the little girl. Usually, two persons grab one leg each and also hold down her hips; a third person holds back the head and torso. To prevent kicks, the child’s legs are held back by tying a rope to each of her ankles which is then tied to her thighs thus keeping each leg in a tightly flexed position in what can roughly be described as a modified and forced Trendenlenberg.If available, this is the stage at which a local anesthetic would be used.

The element of speed and surprise is vital and the operator immediately grabs the clitoris by pinching it between her nails aiming to amputate it with a slash. The organ is then shown to the senior female relatives of the child who will decide whether the amount that has been removed is satisfactory or whether more is to be cut off. After the Clitoris has been ‘satisfactorily’ amputated, and also after the female relatives have ‘ululated’ to let those outside know that the business at hand is progressing well, the operator can then proceed with the total removal of the labia minora and the paring of the inner walls of the labia majora . Since the entire skin on the inner walls of the Labia Majora has to be removed all the way down to the perineum, this becomes a very messy business as the child who is by now screaming and struggling is also bleeding profusely making it difficult for the operator to hold with bare fingers and nails the slippery skin and the parts that are to be cut or sutured together.

It needs to be stressed here that it is important for the wound to heal by first intention not only to protect the child from a repeat operation, but also mainly to preserve the popularity of the operator who would otherwise acquire a bad reputation and also would lose future potential clients if the wounds that she handles do not heal well. Having made sure that sufficient tissue has been removed to permit the desired fusion of the skin, the operator pulls together the opposite sides of the labia majora, ensuring that the raw edges where the skin had been removed are well approximated. The wound is now ready to be stitched or for thorns to be applied.

If a needle and thread are being used, close tight sutures will be placed to ensure that a flap of skin covers the vulva and extends from the Mons Veneris to the Perineum and which, after the wound heals, will form a bridge of scar tissue that will totally occlude the vaginal entroitus. A small hole having the diameter of a matchstick will be left un-stitched in order to permit the flow of urine and vaginal secretions. If thorns are being used, an equal number would have been inserted into each side of the labia majora, and a string would then be used to pull the thorns together and thus bring the raw edges of the labia majora together. The string would be wound in the same way that sports shoes with hooks are laced. If the female genital cutting is being done by a person who has some knowledge of dressing wounds, they would apply regular medical disinfectants.

After the stitching, a raw egg is broken over the wound, which is then sprinkled, with whatever herbs, sugar or concoction that were prepared according to the dictates of the local custom, or the practice of the ‘operator’. This concoction, consisting of egg, herbs, sugar, and the blood of the child, would all clog together and form a crust over the sutures or the strips of cloth holding the thorns together. One can only wonder why more girls do not develop infections after this rich culture medium for bacteria has been placed between the legs of these little girls. In order to prevent leg movement, the child’s legs are bound together from the hips down to her toes and the child is then made to lie on her side.

No dressing is used and the legs are kept together for a week after which the leg bindings are slightly loosened and the child allowed taking small steps. The leg bindings will be removed altogether after a further week. To ascertain that the urethra has not been accidentally closed, either by a blood clot or suture, the child is encouraged to urinate a few hours after the operation. Whether sutures or thorns were inserted, these will be removed on the seventh day but only after the operator is satisfied that the two sides of the labia majora have fused together and that the remaining hole for urination is not wider than three to five millimeters in diameter.

De–infibulation at the Time of Marriage

The closure of the introitus must be reopened at the time of marriage so that the woman is able to have sexual intercourse. The opening up of the infibulation occurs as part of a ceremony and in the presence of female members from the bride and groom’s families to verify that the bride is a virgin at the time of marriage. The opening of the infibulation is performed by a senior female member of the community, a TBA, or in a hospital by medical staff. Occasionally, the husband forcibly performs penetration and bursts through the scar of the infibulation.

The Dangers of FGM

FGM puts children at risk of life threatening complications at the time of the procedure as well as health problems that remain with her for life. They may suffer bleeding at the time of the procedure or develop severe infection, both of which can lead to death if not treated promptly. Those who do not develop life-threatening complications will still suffer from severe pain and trauma.

The procedure also permits the transmission of viral infections such as hepatitis which can lead to chronic liver diseases and even HIV. The women may suffer complications such as recurrent infections, pain and obstruction associated with urination and they are at higher risk of painful menstruation and intercourse, pelvic infection and difficulties in becoming pregnant. Retention of urine and recurrent infections often require repeated hospital admissions and some women carry a risk of developing nephritis. The development of cysts and keloids at the site of the scar are very common, often causing embarrassment and marital problems, and usually require surgery for removal.

During pregnancy there are many further complications that may occur as a direct result of the FGM. Labour may become obstructed and if early medical intervention is not provided this may lead to the death of both baby and mother. WHO estimates that many women giving birth die in the process, simply as a result of FGM 19. If the mother and baby survive there is the risk of damage to the vagina leading to the formation of fistulas into the bladder or bowel, which cause constant incontinence as a result of a vessico-vaginal fistula or recto-vaginal fistula. Women in this condition are often rejected by their family and become social outcasts. During the seven years that the Edna Adan Hospital has been functional, the fistulae of over 100 women have been surgically repaired. Apart from the many physical complications, the girls and women experience considerable psychological problems including depression, anxiety and post-traumatic stress disorder. These psychological problems are exacerbated at the time of marriage and often lead to increased distress and fear of intercourse. If de-infibulation is performed the woman is again exposed to the life threatening complications of sepsis and bleeding, and the transmission of chronic infections such as HIV and Hepatitis and also damage to the urethra if, as is common, the operator makes an error when performing the cut.

Complications

Considering the clumsy and un-hygienic conditions under which female genital mutilation is usually performed, complications are frequent and numerous and can be classified in the order in which they are likely to occur.

Immediate

• Shock
• Fear
• Pain
• Hemorrhaging
• Other lacerations: in addition to the intentional cuts on the clitoris, labia minora and majora, there may be accidental lacerations inflicted on the child as a result of her struggles.

These cuts may involve the vagina, urethra, anus and thighs.

As a result, quite a few children are taken to hospitals for the control of hemorrhage, or for the repair of severe lacerations.

Within the first 10 days

• Infection: infection to the wound and septicaemia are often encountered and tetanus is not uncommon.
• Retention of Urine: (5 possible causes)
  1. Post-Traumatic Oedema of the vulva resulting from the damages inflicted on the clitoris and labia impedes or obstructs the passage
     of urine through the swollen urethra
  2. Obstruction of the urethra by a blood clot or by the thorns that were inserted to hold the sides of the labia majora together.
  3. Accidental suturing of the Urethra itself
  4. Over-tight application of the binds that were used to keep the thighs and legs together
  5. Psychosomatic urine retention out of fear and pain
• Failure to Infibulate: when the two sides of the labia majora fail to fuse, it necessitates that the child undergoes a repeat operation at
  a later date.

At the onset of menstruation

• Dysmeorrhoea: when the post-infibulation vaginal whole is too small there is a constant stagnation of menstrual blood and other vaginal secretions, causing bacteria to spread into the vaginal and uterine cavities. This is likely to increase the risk of chronic pelvic inflammation that might cause the severe abdominal cramps experienced by infibulated females during menstruation
• Recurrent Urinary Tract Infection: because of the flap of skin obstructing the urethra after infibulation, urine does not jet out during micturition. Instead, it hits the flap of skin obstructing the vulva and is then sprayed back into the vagina and then trickles out in drops. This obstruction also prevents proper vaginal hygiene and drainage and causes urinary stasis which is likely to cause recurrent urinary tract infection
• Possible Second FGM: because the small artificial opening that had previously permitted the passage of urine becomes insufficient to permit the drainage of the more viscous consistency of menstrual bleeding, doctors often have to convince the parents of these girls that the small vaginal opening be enlarged to permit the flow of menstrual blood.

This the families resist because they fear that if the opening is too wide it may not be sufficient proof that their daughter is a virgin when her time comes for her to get married.

At the time of Marriage

• De-infibulation: The infibulation opening that had until then permitted the passage of urine and vaginal secretions is no longer able to permit intercourse. This will require that the husband make a forcible penetration to burst the skin obstructing the entrance to the vagina, or the opening will have to be cut open with scissors or a knife to allow the consummation of marriage
• Dyspareunia: the scar tissue that surrounds the vaginal orifice may be rigid and inelastic and can cause pain during sexual intercourse
• Infertility: because of the constant stagnation of menstrual blood and other vaginal secretions that have accumulated in the vaginal cavity, the resulting pelvic inflammation may obstruct the fallopian tubes and block the normal travel of the ovum along the tubes, preventing
  it from becoming fertilized by the male spermatozoa
• Vulval keloids and dermal cysts: apart from their unaesthetic appearance, these may interfere with consummation of marriage or with childbirth during delivery

During Pregnancy

• It is not uncommon for an infibulated and pregnant woman to attend the antenatal clinic for follow up of the pregnancy or for a pregnancy related complaint and find that the opening of the infibulation will not admit the introduction of even one finger into the vagina for diagnostic and exploratory purposes. Such women will require a de-infibulation during pregnancy if complications are to be avoided at the time of delivery

During Labour and Delivery

• Caesarian: Some women arrive at the maternity hospital in labour with a very small infibulation opening. If the vagina is seen to be too rigid and scarred, and thought to be a possible cause of severe vaginal lacerations or third degree tears, it is likely that and elective caesarian section will be decided upon. If keloids have formed and are too large, a Caesarian section might be the best option to deliver this woman.
• Prolonged second stage of labour: because the vagina, perineum and the labia have all undergone mutilation that has left extensive scar
  formation, the vaginal canal becomes inelastic and the pelvic floor muscles rigid. Thus preventing the normal and gradual dilation of the vagina as well as the descent of the presenting part of the child during the second stage of labour
• Foetal Complications:
  1. Large caput formation
  2. Excessive molding of the head
  3. Intra-cranial hemorrhage
  4. Hypoxia
  5. Foetal distress
  6. Intrauterine death
• Maternal Complications:
  1. Obstructed labour
  2. Extensive vaginal and perineal lacerations
  3. Third degree tears
  4. Uterine inertia
  5. Uterine rupture
  6. Impacted foetus
  7. Maternal distress
  8. Maternal death

Post-natal Complications

• Infection of the lacerations
• Delayed healing of the repaired perineum and vaginal tissues
• Sloughing of the vaginal wall, resulting in Vessico-vaginal fistula and/or recto-vaginal fistula
• Anemia
• Puerperal infection
• Cystocele and Rectocele: because of the prolonged labour during each delivery, there is added stretching of the vaginal wall muscles.
  This causes a prolapse of either the bladder or rectum to bulge into the vagina

Other Complications

In recent years and since the HIV/AIDS pandemic, likelihood of transmission of the AIDS virus has become added to the long list of complications associated with female genital mutilation. The risk is made real because the traditional healers who perform circumcisions do not know the dangers of using unsterilized instruments that have previously been used on different individuals who might have been carriers of the AIDS virus.

Reasons Given for FGM

The reasons that drive the practice of FGM lie deep within tradition and cultural heritage and are complex and difficult to determine. Although there is variation between societies there are common themes. FGM is often wrongly believed to have a religious origin or to be a requirement of certain religions but this is not the case.

In the majority of societies FGM is believed to preserve the woman’s virginity before marriage and ensures fidelity during marriage. Other common beliefs include that it is hygienic, aesthetically pleasing or increases fertility.

For many women it is part of social integration and the mutilating process is accepted in return for benefits such as the promise of acceptance in society and the improved prospect of marriage. Older women often believe they have benefited from FGM and that it has been essential to their identity. By the same reasoning they allow it to be performed on their daughters fearing that failure to do so may bring them suffering and social isolation.

Understanding these complex, multifaceted thought processes within societies is key to the design of successful, culturally acceptable and correctly targeted eradication campaigns.

Campaign to Eradicate FGM

The International Campaign

The International Campaign against FGM has a long and difficult history. Advocacy and resistance started with individual health professionals from practicing African countries working in their communities. Their efforts are to be commended as they worked in unreceptive environments with little support. However there are not many records of these efforts and the extent of their impact in not known.

UN involvement in the eradication of FGM

Although the UN support for the eradication of FGM is now strong and active, it was slow in coming. Lack of knowledge on the subject first prevented UN agencies from addressing the issue. When awareness finally came to the UN about the extent of the practice and the serious health and psychological effects that result from it, they recognized it as a major Human rights issue. Conferences were held, studies were commissioned and discussions were finally opened on the topic. However, the mainly European representatives chairing these discussions did not understand the deep cultural ties that propagated the practice and they were unprepared for the resistance they faced by recently decolonized African nations who saw the attention on the issue as another intrusion. There were exceptions however. East African countries, including Somalia where the most severe forms of FGM are practiced and who had more active campaigns were more appreciative of UN involvement. After these first rounds of conferences around the 1980s, it was realized even talking about the topic was sensitive, so immediate abolition was impossible. While mandates condemning Female Circumcision, as it was know then, were taken, in terms of actual field work, the UN took the approach of funding local efforts. These local efforts concentrated on the areas of education and advocacy. Training was needed for the health professionals dealing directly with the victims. Governments were lobbied to create policies against FGM or if such policies already existed to implement them proactively. The general public was educated on the subject, and this was the most important work that permitted the timid steps towards change to be achieved. The struggle continues to this day with varying degrees of success. Complete eradication has not been achieved, nothing close has even been attained, but the topic is more openly discussed now than it was thirty or forty years ago.

The Campaign in Somalia/Somaliland

In March 1977, during the formation of the Somali Women’s Democratic Organization (SWDO), Edna Adan Ismail was the first Somali person to publicly denounce FGM and pioneered the campaign for its eradication in Somalia and in Somaliland. From that time she has campaigned against FGM at many important occasions, including during the WHO Seminar in Khartoum in 1979 on the Mental and Physical Complications of FGM; in 1980 during the Mid-Decade Conference for women in Copenhagen; in Lusaka in the same year; In Dakar in 1984 when she co-founded and was elected the Vice-President of the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children; In 1986 in EMRO Egypt; 1987 in Addis Ababa and the lobbying of the Organization of African Unity. During the Beijing Women’s Conference in 1995 and between 1988 and 1997 when she tirelessly along with international colleagues, lobbied WHO/UNICEF and every Human Rights Organization.

That first gathering of SWDO was a golden opportunity to address the future leaders of women in their respective regions of the country and Edna Adan took full advantage of the opportunity. It was the first time the problem of FGM was spoken about in public in Somalia/Somaliland. Thereafter Edna Adan lectured medical students at the University of Mogadishu as well as nursing students in various nursing schools in Asia and Africa. The subject was included in the curricula of these schools and future health professionals all finished their education with knowledge of the harmful effects of FGM.

In the early 1980’s research into the physical, psychological and sociological aspects of FGM was carried out by the Somalia academy of arts and Sciences. In 1988 the government campaigned to eradicate the practice on health and religious grounds. The SWDO continued their struggle and joined with the Italian Association for women and development (AIDOS) in 1987 and over the following years founded a campaign based on health complications fearing that one based on human rights would fail. Both campaigns collapsed in 1991 with the overthrow of Siyad Barre and of the disintegration of the government in Somalia.

In 1997, at the time when Edna Adan Ismail was WHO Representative in the Republic of Djibouti, UNICEF requested her to assist to obtain the approval of the government of Somaliland for a seminar to be held in Hargeisa to launch the first seminar to revive the campaign to eradicate FGM. The seminar was approved and held and a national committee and a regional task force were established to develop formal policies. This work continues and at the same time a variety of NGO’s and women’s groups also run their own eradication campaigns.

There have been encouraging signs that the awareness campaigns are having the desired effect. A recent Save the Children publication on child rights in Somaliland found that most girls and boys, and some care givers, community leaders and government officials, point to the harmful traditional practices of FGM as the most negative aspect of Somaliland society and culture.

Education and the empowerment of women brought about by eradication campaigns are changing the views of Somalilanders on FGM, but it is only by the implementation of audits like this one conducted at the Edna Adan Hospital that the rate of change can be accurately recorded and evaluated. In a society where the practice is almost universally accepted change will occur slowly for as long as people fear discrimination for choosing to break with tradition.

The Edna Adan Maternity and Teaching Hospital is a major player in the campaign against FGM. The next pages provide information about the hospital and its vital role in this work.

The Hospital and FGM

The Edna Adan Maternity and Teaching Hospital confronts the effects and complications of FGM almost on a daily basis. Cases include children who have been mutilated hours and sometimes days before being brought to the hospital and who are still bleeding quite heavily or unable to pass urine because of their new stitches. The severest case of a mutilated child seen at the hospital was one where the child had been so badly cut, that there was virtually no skin to suture together to stop the gushing blood coming from her little body.

Common cases also include newly married girls and women just de-infibulated and suffering from bleeding, infection or just plain pain. Also, women in Labour for much longer than they need be because scarring due to FGM prevents the birth canal from dilating properly. Some of those women end up with third degree lacerations and other post natal complications.

Edna Adan has been dealing with cases of this nature in her 50 years of midwifery experience and has been engaged in a life-long struggle to see the end of this practice. With the establishment of her maternity hospital and with the still much needed services to deal with FGM, It has become essential for the hospital to lead the campaign. it is fast becoming a repository of all information relating to FGM in Somaliland and the region. The hospital has started an auditing process to have baseline data about the prevalence of FGM and the survey in this report is the first data to come out of that auditing initiative and it is believed to be the first of its kind in Somaliland. The hospital holds educational and sensitization seminars for concerned groups. At a patient level, counselling services are provided to the victims of FGM and their families. There is no other institution in the country better equipped with the experience, knowledge, facilities, and above all, dedication and sheer ‘Will’ to tackle this issue.

The Study

Female Genital Mutilation Survey Questions

Female Genital Mutilation Survey Questions

This study was compiled from a survey carried out on the women attending the Prenatal Clinic at the Edna Adan Maternity and Teaching Hospital in Hargeisa, Somaliland between March 2002 when the hospital was opened up to August 2006. The findings were diligently recorded on the Prenatal Charts of each woman so that the information could be compared with future findings during subsequent surveys.

The data that was obtained has provided information on the prevalence of FGM, the type of procedures that had been performed on the persons examined, the ages when the procedure had been performed on them, and details of those who had performed it on them. The data also provided an insight into what motivates the continuance of the practice and a prediction of the future risks to young girls. It is believed that the results from such a reliable audit on the prevalence of FGM would be a crucial element in achieving the goal of eradication of the practice since the information obtained can be used as a baseline data for directing future awareness campaigns and auditing their success. Finally, the data collected is of interest to the local community in Somaliland and also to medical professionals, NGO’s, International Aid agencies, women’s groups, and to all those who are fighting the practice wherever they may be in the world.

The Edna Adan Maternity and Teaching Hospital is the main site in Somaliland for holding campaigns against FGM. Its founder and director, Mrs. Edna Adan Ismail is a pioneer in the fight to end FGM in Somalia and Somaliland who started her advocacy work on the subject as far back as 1977.

Purpose of Survey:

Female Genital Mutilation Chart

Female Genital Mutilation Chart

• To obtain baseline data on the current prevalence of FGM among women of childbearing age attending the prenatal Clinic of the hospital.
• To obtain information about the prevalence of each type of FGM
• To record data on observed complications in pregnancy, Labour, and delivery
• To collect data on the age when the procedure was performed, who performed it and where
• To collect information on why the women think the practice is done; whether they are pleased it was done on them; whether they will
  do it to their daughters and why
• To determine whether any progress has been made towards attitudinal changes after 32 years of campaigning
• To use the information obtained for future planning of actions to eradicate the practice

Methodology of the Data Collection.

Reasons Given for Practice of FGM

Physical Examination

Examination of the vulva of the patient as part of the physical examinations carried out on all pregnant women attending the clinic for Antenatal Care. On occasions, it was not clear whether the person had undergone any form of FGM and a confirmation was obtained from the woman herself to record whether the answer should be a ‘Yes’ or a ‘No’. If the answer was a ‘No’, it would be recorded as such and the finding was included in the number of women who had no FGM performed on them. If the answer was a ‘Yes’ then the rest of the questionnaire would be completed.

Questionnaire

In order to ensure the uniformity of the data, a simple questionnaire was developed and printed on the Antenatal Cards of the hospital so that all women who attended the Antenatal clinic had the findings recorded on their individual patient card.

Recommendations

The battle for the abolition of FGM is definitely one that is too difficult to be left to individual crusaders and little old women.
It has to be fought by all and particularly by government and by professionals such as Obstetricians, Gynecologists, Pediatricians,
Nurses and Midwives who are the ones who have to deal with the serious complications caused by female genital mutilation.

Strategies for the eradication of FGM

1. GETTING A LAW IN PLACE IN SOMALILAND
   • To date the government has made no legal declaration or resolution against FGM. The first priority is to lobby the government to enact a law forbidding the practice.
   • The international community needs to play a more important role in assisting the government to put such a law in place.
2. RELIGIOUS LEADERS ARE KEY
   • More than any other group, religious leaders are looked up to for trusted advice and social direction. If they state with a unanimous voice that FGM is prohibited in the Islamic religion, it will go along way in convincing the general population to abandon the practice.
   • UNDERSTAND: FGM is thought of as a women’s issue. Somali men don’t generally think very much of it, that includes religious Somali men too. Most have probably never considered the legality or illegality of FGM in a religious context. They can be made aware of existing religious scholarly work available on the subject. If possible they can be sent for training and sensitization to religious centres and universities in Islamic countries to learn from the experiences of communities who have abandoned the practice.
   • SUPPORT: Other initiatives that have undertaken the sensitization of religious leaders have found that once this group understands the issue and the severity of the problem, they become strong supporters of its abolition.
   • ADVOCATE: from support to advocacy. Once religious leaders are on board their stand must be shown to the public; Through the weekly sermons in Mosques, through television and radio programs, through religious schools or madrasas. Information tools such as video cassettes and tapes with recorded messages can be developed so their testimony can be taken to remote locations. These key agents of change must be put to full use.
3. SENSITIZING FRONT LINE HEALTH PROFFESIONALS
   • MORE PEOPLE: Sensitizing front line health professionals will increase the number of persons in the field actively working against FGM
   • ONE VOICE: FGM training must be uniform, to increase impact and avoid mixed messages. Partners working against FGM need to coordinate efforts to ensure a consistent training approach
   • TOOLS: training needs to include tools health professionals can use to counsel and if possible intervene in FGM. Tools could include booklets and pamphlets, videos and cds etc, all in the local languages of the communities being addressed
   • DATA: informed and equipped health professional can help collect data about the current state of FGM in Somaliland as well as keep a record of the progress they make in their individual locations
4. SENSITIZING THE COMMUNITY
   • GIRLS AND YOUNG WOMEN: need to be targeted directly so they become informed about their condition and options. Establishing communication with this group at an early age can influence decisions they make regarding their own daughters later on.
   • Efforts should be made to make FGM education as part of the regular curriculum of all schools for health professionals.
   • PARENTS: and especially MOTHERS As the primary decision makers of FGM, are the most essential group to persuade. Contact with them needs to be consistent and continuous if progress is to be made in the campaign.
   • MEN: FGM : although they may not think much of it, FGM is done primarily to garner their pleasure, and to secure marriage proposals from them. They need to be brought into the picture and informed of the undesirability of the practice from a health stand point, cultural standpoint and sexual relations standpoint. If this group no longer feels that a girl must go through FGM in order to be suitable for marriage, then the stigma of being free of FGM can be alleviated and more families will have the freedom to abandon it.
   • BUSINESS PEOPLE and PROFFESIONALS This group falls into the category of those who have weight within the community. Generally they have a higher level of education and have an appreciation for Health matters. Educating them about FGM can effect the decisions they make in their own families and the advice they dispense in their circles of influence.
5. USING MEDIA TO ESTABLISH A PERMANENT PRESENCE
   • The campaign against FGM cannot be a sporadic nor an annual event. This is a serious human rights and health violation issue that effects young children and women. There must be a strong and permanent presence, through boards and pamphlets, videos and cds, seminars and workshops, websites and blogs. But these efforts need to have a smart design that combines sensitivity with practicality.
6. RESEARCH
   • Much research needs to be done on FGM in the Somali regions. As of now there is no reliable data although this study aims to remedy that. But there is still much more work that needs to be done.
   • POSSILBE RESEARCH QUESTIONS:
     • More data on Prevalence is needed and types of FGM performed.
     • Which type of FGM is more frequent?
     • Why do those who choose type 3 make that decision?
     • Why do those who choose a less invasive type make that decision?
     • Can the underlining reasons for choosing one type vs. another be used to influence families to choose a less invasive procedure or to abandon the practice altogether?
     • What about those that have not undergone FGM? How did they come to that decision? What kind of difficulties have they faced? What would
       have made their choice easier to live with?
     • What are the correlations between education and FGM? Income and FGM?
     • Most Somalis have family members living abroad who maintain strong ties and who send remittances. How do Somalis in the Diaspora feel about FGM?
     • Do they have any influence over their families in their homelands regarding FGM? Can this connection be used in the eradication campaign?
     • What ideas about women’s sexuality are inherent in the practice of FGM?
     • Are those reasons openly spoken about or more hidden?
     • What about Age, Attitude and FGM? How do youth, male and female feel about it? Can intensive education campaigns aimed at this group help to stop this practice?
     • What about health professionals? They’re expected to be partners in the elimination of FGM but what are their personal views on the subject? Do they practice the custom in their private lives?
     • How about religion and FGM? Can a campaign more focused on the religious impermissibility of the practice be more effective than one
       that stresses health complications or human rights violations?
   • MONITORING AND DOCUMENTING
     • To take full advantage of resources and to measure achievements when necessary, careful monitoring and documenting techniques must be applied.

These recommendations show the need for a wide, and all-encompassing approach in the fight to eradicate Female Genital Mutation. Because the practice is so pervasive, all areas of society must be targeted, simultaneously and continuously.

Political Power: The Challenges of Sexuality, Patriarchy and Globalization in Africa

Patricia McFadden

Let me share with you some of the reasons why I think this moment—this time we are living in—is special, because these ponderings provide the context of my reflections on how power intersects with the notions of sexuality, patriarchy and globalization—the subject of our conversation this evening.

The specialness of this moment lies in its being the culmination of many long and difficult struggles, especially within Southern Africa, for dignity and peace. Each and every one of us is the custodian of a sacred memory, drawn from the long battle to free ourselves from colonization, racism, bigotry, backward feudal practices and conventions as well as the so-called 'civilizing' agendas of capitalist modernity as they have unfolded, often with great pain and heart rendering loss, these past five hundred years. This moment brings together all the energies and desires that we have whispered quietly or shouted out in great anger across the landscapes of this place we call home. 

Many times we have found ourselves at the place of great mourning—as did those enslaved foreparents who threw themselves off the great heights of the mountain rather than return to the indignity and denigration of enslavement—a choice they had to make given their knowledge of the monster that pursued them to that end; and it is at those times of great challenge that we have to step back, take a deep breadth and pause in order to be able to review the past so that we might understand the present and through that craft a new and different future. And this moment gives us the opportunity to do exactly that.

Most significantly and in a very intimate way, this is a moment which is finally of our own making; a time that has come out of the imperative to be Africans in our own ways; an opportunity which we have crafted and nurtured through an unfailing belief and conviction in our ability to change our worlds/our lives/our futures as women; as workers; as citizens of our national and continental spaces and increasingly as citizens of the world.

So this evening, I want to lean back and reflect upon what it means for those of us who believe in freedom to accept the challenges which patriarchal privilege and exclusion present, and I would like to use three key issues—the notions of the political as personal and inclusive; integrity and personhood; and rights and citizenship—to open up the terrain of discourse in the hope that this short sojourn will take us one step closer to a resolution of the century old problems of injustice and oppression in all our societies.

I will first of all assume that this audience does not require my re-statement of the consequences of globalisation in economic and political terms because the evidence is clear for all of us to resist—the threats to basic services like health, education, affordable transportation and shelter, access to dignified and safe employment and the guarantee of our rights as citizens without exception. Therefore, I will refer to the notion of globalisation as an ongoing context made up of historically recognizable forces that are once again attempting to restructure the world in order to maintain hegemonic systems of exploitation and privilege.

However, this is only one side of the notion of globalisation. I think that we need to explore another, often less recognized side of how our world is changing or has changed—that of the emergence of international coalitions and movements of resistance around the lives of women and poor people. These are the coalitions to defend the eco-systems and environments that have sustained our livelihoods and very ability to exist as a species; the movements for the rights of people who move and or are coercively moved around the globe in search of political and economic security, fleeing religious fundamentalist persecution, or simply exploring the immenseness of this planet. There are also movements, almost a century old, to resist the militarization of the world and the ever-present threat of nuclear destruction which knows no boundaries; these are movements which have made the issue of peace central to our understanding of what globalisation means for all of us in a much more diverse and less defeatist way.

This is my context—to locate some of what I think are the most pressing issues facing us as Africans within a context of modernity that requires that we envision a new and different future, even as we remember the lessons and mistakes of the past.

Power and Democracy as Historically Exclusionary Practices

Throughout the human narrative in all but very exceptional cases, which are rare and often romanticized, power and notions of freedom and justice have remained deeply class based and androcentric, reflective of the opinions and interests of ruling class men, regardless of their colour or location in spatial terms. And even when such systems aspired to be inclusive and socially expansive, they remained essentially exclusionary and patronizing of those who had been constructed as Other in relation to power as the most critical resource in that society. Across our world we struggled for what appeared to be collective visions of freedom and justice, and while it is critical to acknowledge the opportunities that nationalist liberation struggles and anti-colonial resistance provided to those groups in our societies which had been up till then excluded from the public, for example women, we must also critically evaluate the implications of nationalism as an ideology which is fundamentally sexist and exclusionary of women, particularly during the neo-colonial period. However, the very notion of the public space emerges as an expression of the development and existence of surplus pegged largely on the unpaid labour of women in the home and the unremunerated labour of enslaved communities in the wider society.

It is within this milieu of exchange that new relationships of property and power rise which are institutionalized in new structures that over time become known as the public—a space and a concept which reflects the new relations of production and civic interaction. It is here that the state and the key institutions of the society are located and dominated by men as a gender and as the owners of wealth—both material and social. Juxtaposed to the public space where men are 'free' to roam, always of course in relation to their status, the notion of the private arises out of the definition of women as the private property of males, located in male headed households. Even to date, women cannot form a family on their own, as a legal entity in all our societies. They have to marry men in order to create a legally and socially recognized unit called the family. Through rituals and practices that have become euphemistically understood as 'cultural' and 'traditional', women's capacities and abilities to labour and to reproduce are institutionalized in the patriarchal family as the private property of their fathers and husbands. It is at this interface between human creativity and the existence of surplus that the most crucial relationships of power and control become embedded, especially in relation to women.

Over time, women, like poor men and the young, became excluded from the resources that were located in the public, and a dualistic system of rules and regulations were formulated which have kept women largely in the private—working long hours without remuneration for their labour—which is one of the main reasons why women remain the poorest people in the world, and like the slaves, women have been excluded from the rights and civic entitlements that emerged out of the various struggles enacted in the public. Therefore, while it is important to show the linkages between gender and poverty across the female/male divide, it is even more important to recognize that poor men have always had access to the public sphere where they are able to engage in struggles for fairness and economic and social justice, while women have remained largely tied to the private sphere where they continue to be treated as the slaves of men in the heterosexual family, even in the families of those men who struggle against economic enslavement.

In all our societies across this continent, men have colluded to keep women out of the public sphere where rights and entitlements are located (we know that there are no rights in the family, only privileges and benevolent gestures and much violation, exclusion and death), and even as we laud the struggles against colonization, we often shy away from the acknowledgement that most black men colluded with the colonial state in the exclusion of black women from the cities and those sites where the possibility of becoming free was located. To date, even after almost fifty years of independence, all African governments have retained the vicious socio-legal and coercive practices that exclude and suppress women and female children, which characterized feudal African societies and were further refined by the colonial state with the assistance of privileged African men. The present re-institutionalisation of traditional courts and traditional statuses in the political and legal systems of a country like South Africa speaks most tragically to this ongoing collusion between men of different classes and colours to exclude women from the democratic institutions and practices we have fought so courageously to build.

The maintenance of the public/private divide through claims of cultural authenticity and the need to hold onto so-called 'traditions'—which we all know are basically practices and value systems that privilege men in the home and in the key institutions of our societies—has inhibited the greater participation of women in the transformation of Africa to the present day. Notions of what is political and public are still fundamentally tied to the claim that what women know and do is best suited to the production of use values for household consumption and the reproduction of the species. Even in societies where women have excelled as professionals and knowledge producers, they are faced with a continuous backlash, often premised on fundamentalist beliefs that so easily mobilize communities to participate in the undemocratic exclusion of women from their rights. One has only to look at the issue of taboos around the sexuality of women and how these taboos are perpetuated through fundamentalist claims that are centuries old and viciously misogynist—allowing, for example, women to be raped and violated by claiming that women bring such violation upon themselves through the ways in which they dress and by the very nature of their female bodies as 'unclean' and 'sexually dangerous.'

In all our societies we find the blatant justification of the victimization of women by men in key positions—within the judiciary, in organized religion, within families, and in social and cultural organizations, which deploy ancient patriarchal myths of exclusion and privatization to defend impunity. By impunity I mean the deliberate, socially sanctioned violation of rules and systems of human conduct that are the collective possession of a society, and which have been designated as the markers of human dignity. The notions of integrity and personhood lie at the core of human dignity and decency, and we all learn these from the moment we enter a human space. 

Every human being is born with the inalienable right to physical, emotional and sexual integrity, and the nurturing process in all our societies recognizes the importance of not only protecting the integrity of another human being, particularly while they are young and vulnerable, but is also anchored on the transmission of these notions to the individual as untouchable and inalienable rights. This is why we abhor slavery and fight to the death to remain free.

Yet the very people who understand the centrality of human integrity as a civic right are often those who engage in and support practices and so-called 'customary laws' that violate and undermine the physical, emotional and sexual integrity of women and girls—in the name of culture and male supremacy. 

In my opinion, and through my work as a radical feminist who is totally uncompromising on the rights and entitlements of women wherever they live, this impunity, which lies at the heart of violation and social injustice in all our societies, is embedded in the privatization of women within the key social and political, religious and cultural institutions across this continent and the world at large.

Therefore it is critical to understand that in as much as the private/public divide, which has facilitated the construction of power in essentially class and masculinist terms within most of our societies, continues to be challenged and resisted by women's and other social movements, the major difficulty in making the political inclusive of everyone lies in the persistent exclusion of women as citizens of our societies. Unless we are able to see the interconnectedness of impunity as it is culturally, politically, economically, religiously and legally framed and sanctioned we cannot begin to respond effectively to the imperative of restructuring our societies in sustainable and democratic ways.

We have to see the culturalized expressions of impunity (through female genital mutilation, male child preferences, unfair eating practices, incest, witch-hunting women, especially older women and widows, child marriages and coerced marriages, and feminized altruism) in order to debunk them and declare them criminal offenses against citizens in each and every instance. Only in this way can we begin to replace them with new democratic, life-enhancing cultural notions and practices.

We have to reject outright (and not try to reform) those legal systems that are partial and often blatantly patriarchal: for example, the persistence of notions of male conjugal rights; refusals to recognize marital rape as a crime; allowance of polygamy and rampant sexual mobility; notions of paternity which define children as the property of the man rather than emphasizing the responsibilities and obligations of parenting in democratic family relationships; inheritance practices that allow men to inherit women as a form of property/as slaves of male controlled families; and a myriad of injustices that are allowed to circulate and reproduce themselves through the often deliberate misrepresentation and/or insistence by judicial officers that women cannot be considered persons in the ways that men are.

We must critique the exclusionary economic practices (which globalization is reinforcing and extending to every aspect of human life) that are deepening the immiseration of women and young people through a rhetoric of dog-eats-dog; dangerous claims which have become normative and naturalized as the only reality possible. How unthinkable that we could be living in a world where the narrow, sectarian claims of a voraciously greedy class could assume such public hegemony and go so largely unchallenged even by those who know that it is a blatant lie.

We have to make the personal political by transforming the meaning of politics from its current definition as men contesting power by any means—including and especially through the making of war and the use of our resources at the expense of millions across this continent, while its citizens become refugees; non-persons in flight, without any rights or securities. We have to change it to a notion and practice of politics that guarantees the rights and securities of all citizens, all the time. We have seen over and over these past decades a worsening situation in numerous African countries, as the African petite bourgeoisie finds itself less and less able to accumulate competitively with the ruling classes of the North. Africa has remained 'economically marginal' in the capitalist global system, even as we know that for centuries our resources and knowledge have fueled the 'development' of Northern societies and continue to be crucial to the maintenance of their current notions of democracy.

However, for the African petite bourgeoisie, the crisis of reproduction has been intensified by the concentration of wealth globally in the hands of a smaller and smaller number of Trans-National Corporations that are poised to take over the state in the North as they have done to a large extent in Africa and in the rest of the South. 

The Multilateral Agreement on Investments agenda was precisely about that—making capitalist privilege the ultimate priority in every sense of the word and deed. We also know that in the history of human existence, war has always been a means of class accumulation by those elements that occupy the state—a patriarchal state that ensures the privilege and supremacist ideologies and systems of a small group over the rights and entitlements of the vast majority. Today we can see the coincidence of globalized class interests with those of an African ruling class in almost every African theater of war. The generals are consolidating their class statuses by looting national treasuries and extending the arenas of war and destruction across national and regional boundaries. A re-structuring of the relationships within and among the ruling factions that occupy and use the African patriarchal state is clearly visible when we look at the ongoing devastation of the Congo and the parties involved in that debacle. Sierra Leone, Eritrea, Ethiopia, Angola, Rwanda, Burundi, Algeria, Sudan, Liberia, Nigeria, etc, etc—war has become the everyday tragedy of this the most beautiful and unquestionably most bountiful continent on earth.

That is why the normalization of war through the militarization of our societies and regions, under the guise of so-called pan-Africanist rhetoric, is totally unacceptable and must be exposed for what it really is—the plunder and accumulative rampaging of gangs of middle-class bandits who openly defy the demands of the people for accountability and democratic responsibility. At this point in time, we have to fight to retain the very language of anti-imperialist resistance and to keep the memory of enslavement and colonization alive because it belongs to us all—always—until our worlds are no longer determined by racism, classism, sexism, fundamentalisms and pernicious forms of sectarianism and communalism. Certain groups of Africans are deploying a collective memory in the justification of an openly militaristic class project that is costing the lives of millions of Africans and has laid waste to great swaths of this continent. This nationalist opportunism must be exposed and the rights and security of the African citizen must become the most important priority of all. We can no longer allow selfish class interests to dominate and destroy a continent that belongs to us all.

We have to find the courage to go beyond the hypocritical rhetoric of regional integration that in actual fact only facilitates for greater accumulation by both national and global capitalist forces, at the expense of the basic human and social rights that African working people have fought so courageously to attain. For me, the interface between class, gender and racist/communalist interests is the site where the most critical and most productive contestation has to take place. We need to understand the phenomenon of globalisation, in its multifarious forms, as a re-structuring of the old, hegemonic relationships of economic and political power, which are mobilizing technology, new notions of space and communication, and the political lapse in radical politics to make up for whatever was lost to them during de-colonization and liberation struggles across the world.

Women's Politics as the Source of a Sustainable Alternative Political Vision

As a feminist, I draw my intellectual and political resources from the struggles of women on this continent—land and sea—and from the pursuit of rights by women globally. For centuries women have fought private and public battles to make the world safer for themselves and for those with whom they live, and it is this fundamentally inclusive epistemology that informs women's politics across the ideological and political divide within what we call the Women's Movement. This is where one of the most critical political resources to a different future lies, and I would like conclude my presentation by indicating some of these political gems that are so often unseen or even misunderstood by so many progressive men in the workers' and youth movement in particular.

Firstly and most fundamentally, women's struggles against patriarchy have made visible the intersectionality of all known forms of exclusion and oppression—racism, class exploitation, sexism and chauvinism, paternalism, ableism, and heterosexism. By rejecting all these expressions of injustice, women have brought together in a social movement for rights the totality of issues that underpin patriarchy as an ideology and a system of privilege for the few over the interests of the majority. Women's struggles have, for the first time in the human narrative, made visible the interconnectedness of all systems of injustice in ways which neither the struggles of workers or of poor people in general have done.

Secondly, by raising the essential issues of integrity and personhood, women's politics has challenged the bifurcated nature of notions of justice and equality at every level of their societies, rupturing the public/private divide which still keeps millions of women the world over outside those civic resources and spaces where rights are embedded and secured. As we know, the notion of rights is intimately linked with the demand for the social, economic, political and legal recognition of human value by those whose labour and reproductive capacities were appropriated and exploited by the ruling class. Men who laboured without pay came together to collectively demand the right to paid work and the recognition of their labour as valuable. It is in the valorization of human labour that the right to a dignified life becomes possible, and through a publicly recognized engagement with the market and the demand that profit making not be allowed to keep the worker enslaved to the owners of capital, workers have been able to win the rights that define them as a class in all our societies.

Through the demand that women's rights must become human rights, women have drawn from the struggles by workers and colonized people and are insisting that the notion of human rights itself is partial and unsustainable unless and until it encompasses fully (without a single cultural compromise) the total rights of women to physical, emotional, sexual and social integrity as complete persons in all their societies. The demand for integrity and personhood lies at the core of women's sexual and reproductive rights and this campaign has been most instrumental in taking women's unmet sexual and reproductive needs out of the private where they were considered 'domestic matters' and locating them in the public, making them a political and policy issue and requiring that the state and the major institutions of the society not only recognize these rights as legitimate and inalienable, but also provide the material and infrastructural resources to sustain them. The extension of these rights to all women in all our societies remains a major challenge which globalisation as a retrogressive process is making even more difficult.

 In response to the specific impacts of globalisation in this regard, women have formed global coalitions around the issues of sexual and reproductive rights and health, meeting in various international conferences (Beijing, Nairobi, Mexico, and at the level of the UN and the Economic Commission for Africa) to insist that states not only ratify the conventions and international instruments that women have formulated, without reservation clauses, but also that states, as the assumed custodians of citizens rights and entitlements, must undertake to implement such policies in order to safeguard the sexual and reproductive rights of women in totality.

This has met with a tremendous backlash, the use of so-called cultural appropriateness and slogans of authentication that seek to fragment women's rights through the claim that sexual and reproductive rights are 'western' and 'un-African'. Of course we know that when women demand their rights they become inauthentic and un-African and that is exactly what we aim to do. We will subvert the archaic notions of what is African as we insist on becoming modern and free; and we will re-define and re-structure relationships of power and control, surveillance and exclusion as we claim our democratic rights to be citizens in the fullest ways.

 Therefore, African men can moan as much as they want—while they remain locked in backward notions of what is African and practice western modernity in every other way but towards Africa women. We will not be stopped by patriarchal claims and threats.

In reality, however, these claims and threats often become translated into life-taking expressions of the backlash, and the vilification of women's rights activists and women who claim their rights is real and requires the urgent response of all progressive men in our societies. This is not a matter only for women to resolve, because fundamentally it is about old systems of male privilege which all men benefit from in one way or another. 

Therefore no man is exempt from the political responsibility of fighting for the sexual and reproductive freedoms of women; for women's integrity and personhood and for our right to be total citizens in both the public and private spheres. But, in addition to recognizing and defending all women's rights, men have to begin the process of moving themselves to a new gendered and male identity by interrogating their location within patriarchal society as men. How could it be that male comrades spend their lives critiquing and resisting capitalism and fundamentalisms of every kind, except those that construct them as males in deeply essential ways? At the core of masculinity lies heterosexism and male systems of privilege that underpin impunity and supremacy—even if not used by individual males in their relationships with women.

As a radical feminist I know and understand patriarchy in its most intimate and most pernicious forms, and almost never allow anyone to oppress me in any way. (Sometimes I am not sufficiently vigilant and do find myself in situations where I have been excluded and victimized in some way. However, I deal with that immediately—it is a promise I made to myself long ago and to which I am committed.) But feminist and women activists never assume that because we are able to defend ourselves we do not need to restructure the societies we live in so that all women can access their freedom and the rights that we have begun to exercise. Progressive men have to do the political work of transforming maleness and masculinity. It is not enough to be a good man—you have to be a revolutionary man so that women do not have to do this work for men, which we cannot do anyway. Everyone has to free her/himself as we all know.

Finally, the Women's Movement is without doubt one of the most vibrant and most sustainable movements globally, and through the creation of national, regional and global coalitions and networks, women have begun to change the world in very significant ways. In Africa, women's demands for justice, peace and equality have shaken the foundations of old patriarchal assumptions about what is normal and acceptable. Women have begun to change the character of the public through educational and professional achievement and contestation. We are changing the meaning of science and knowledge by challenging the old dogmas and paradigms that excluded our experiences and opinions. 

At the level of the law the changes have been astounding and absolutely marvelous—in most African societies impunity no longer rages as an absolute force, although it remains a key challenge in the transformation of those areas where women's lives are most undemocratically and most dangerously affected. Politically, women are challenging the state and its hegemony over the meaning of citizenship; women are questioning the assumption that the state is the best protector of common property, and in countries like Zimbabwe, where a neo-colonial state simply took over from the colonial state in terms of being the 'middle-man' in relation to the land as a common resource, women are demanding that the state step aside and let the citizens relate directly to the land as a critical economic and socio-legal resource. The same is happening here in Mauritius and in many countries on the continent.

By changing their relationships with the state and with males in both the intimate and public spheres, women are becoming post-colonial in new and exciting ways. In my opinion, the challenge and disruption of old patriarchal relationships that constructed women as private or communal property and men as the natural heirs of all power in our societies speaks to the emergence of a 'post-colonial' consciousness among women (and among poor men who are challenging the neo-colonial state from where they are located as workers and peasants and homeless/landless persons) which will form the core of a sustainable anti-golbalisation strategy in the future. 

In addition to understanding how capitalism and neo-imperialism work at the levels of macro-economic strategies, cultural and technological hegemony, the military-industrial complex and the use of guns, human trafficking and drugs, we also need to focus on our own political traditions and the resources being generated by our social movements at the national, regional and global levels. 

While we have to understand how the World Trade Organization and General Agreement on Tariffs & Trade work to extend and intensify capitalist exploitation and human misery, and remain vigilant about the resurrection and pernicious implementation of the Multilateral Agreement on Investments agenda, we also have to put more energy into the re-formulation of our capacities to think, mobilize and transform ourselves and our societies in ways which will finally rid us of the scourge of human-invented systems of greed and inequality. After all, globalisation is just a fancy term to describe patriarchyi in its most nefarious form.

Patricia McFadden is a well-known African feminist, born in Swaziland. She was women's policy coordinator for the Southern Africa Regional Institute for Policy Studies (SARIPS) in Harare, and is currently on a Ford Foundation fellowship to the Five Colleges Women's Studies Center at Mount Holyoke, where she is writing a book on feminism and nationalism.