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RHO archives : Topics : Harmful Traditional Health Practices
Overview/Lessons Learned
- Introduction
- Integrating culturally based health systems
- Female genital mutilation
- Dry sex and vaginal drying: Harmful practices?
- Virginity testing
- Sex-selective technologies
- Lessons learned
Introduction
In April 1997, the World Health Organization, the United Nation's Children's Fund, and the United Nations Population Fund issued a joint statement that summarized the importance as well as the challenges inherent to addressing harmful health practices: "Human behaviors and cultural values . . . have meaning and fulfill a function for those who practice them. People will change their behavior when they understand the hazards and indignity of harmful practices and when they realize that it is possible to give up harmful practices without giving up meaningful aspects of their culture."
Health professionals worldwide struggle with how to address harmful health practices. The basic question of whether a practice is harmful or necessary is often hotly debated—debates that sometimes rely on simplistic divisions between "Western" and local medical values. In many cases, this division masks more complicated reasons for defending harmful practices, the victims of which tend to be women and children and others who are less powerful in their society. These reasons often include power struggles, local and national politics, and/or lack of understanding about the risks of the practice.
Sometimes a harmful practice is so deeply rooted that it seems impossible to change. But in every country people have pushed forward positive social changes, and harmful practices have been ended. For example, foot binding was once the norm in many parts of China. Women without tiny, hobbled feet were considered unmarriageable. Women were completely dependent on men since they were unable to walk well. Yet the practice was eliminated in a short time, in conjunction with major political, social, and economic changes in that society. In nineteenth-century Europe, women endured pain and physical damage from constrictive whalebone corsets which caused their waists to appear slim. This practice was also recognized as dangerous, and fell out of favor.
At the same time, Western medicine is recognizing the benefits of some traditional health practices, which fall into an overarching category described by some as "Indigenous Knowledge." Traditional plants are being researched by drug companies, and the health benefits of non-Western therapies such as Indian yoga, Chinese acupuncture, and African community support systems are increasingly being recognized. As leaders in Western medicine learn more about helpful traditional practices, and vice versa, health professionals in all countries can draw from the best of these worlds in order to help their clients make healthy choices.
Listed below are some traditional practices that have an impact on reproductive health.
Positive Practices
- Healthy postpartum practices based on spiritual framework, including rest, cleanliness, love, and good nutrition: Korea
- Long period of breast feeding: many parts of Africa, Latin America, and Asia
Harmful Practices
- Female genital mutilation: primarily Africa
- Early marriage: Asia, the Middle East, Africa
- Severely restricted weight gain during pregnancy: Philippines, France, other countries
- Withholding colostrum (initial breast milk with special nutritional value) from newborn: China, Guinea Bissau
- Low levels of breast feeding: United States, France, other European countries
- Postpartum nutritional restrictions: Latin America
- Vaginal douching: United States, selected European countries, other countries
- "Dry sex" practices (removal of vaginal fluid with absorbent materials): Africa, Latin America, Southeast Asia
- Breast and penis implants: United States, Europe, Southeast Asia, other countries
Integrating culturally based health systems
Western medicine is based on scientific beliefs that practitioners use to understand and interact with human biology. Traditional, folk, herbal, and many other types of "medicine" are generally built upon other sets of belief systems that have a greater emphasis on psychological, social, and spiritual health. A sampling of major global health belief systems includes the biomedical model (e.g., Western, allopathic medicine), osteopathy, and homeopathy; the Asian models, including Chinese, Japanese (Kampo), and Korean (Hanbang) systems; Taoist and Buddhist healing traditions; Ayuvedic (popular in India); and Hmong. Latin American traditions often blend Native American, European, and African heritages, including Santeria, Espiritismo, and Curanderism. African traditions include a wide range of healing practices, some of which date back thousands of years.
By Western medical standards, many of these psychosocial elements have been proven to affect health outcomes. Yet when Western practitioners encounter other cultural health practices, they may dismiss them as irrational. As a result, patients may be reluctant to disclose any other cultural medical practices they use. Since these practices can affect Western medical interventions, however, Western practitioners must be aware of—and understand—these practices.
Each of the systems listed above have beliefs and practices related to reproductive health. Tools like the Patient Explanatory Model and the use of "Cultural Brokers" can help health care providers learn more about the influence of non-Western medicine on their patients' reproductive health.
Female genital mutilation
It is estimated that at least 2 million girls are at risk of female genital mutilation (FGM) each year. FGM is practiced in at least 26 of 43 African countries. Prevalence varies from 98 percent in Somalia and 97 percent in Egypt to 5 percent in Uganda. The practice also is found among some ethnic groups in Oman, the United Arab Emirates, and Yemen, as well as parts of India, Indonesia, and Malaysia. FGM has become a health and human rights issue in Australia, Canada, England, France, and the United States, due to the continuation of the practice by immigrants from countries where FGM is common. For more information, see the PATH website's facts about FGM (www.path.org/resources/fgm_the_facts.htm).
FGM comprises all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for cultural or non-therapeutic reasons. In 1995 the World Health Organization developed the following four broad categories for FGM operations:
Type I: Excision (removal) of the clitoral hood with or without removal of part or all of the clitoris.
Type II: Removal of the clitoris together with part or all of the labia minora.
Type III (infibulation): Removal of part or all of the external genitalia (clitoris, labia minora, and labia majora) and stitching and/or narrowing of the vaginal opening leaving a small hole for urine and menstrual flow.
Type IV (unclassified): All other operations on the female genitalia, including pricking, piercing, stretching, or incision of the clitoris and/or labia; cauterization by burning the clitoris and surrounding tissues; incisions to the vaginal wall; scraping (angurya cuts) or cutting (gishiri cuts) of the vagina and surrounding tissues; and introduction of corrosive substances or herbs into the vagina.
These procedures are not reversible, and their effects last a lifetime. Types I and II account for up to 85 percent of FGM operations. Type III is common throughout Djibouti, Somalia, and Sudan, as well as in parts of Egypt, Ethiopia, and Kenya. While health complications occur most frequently with Type III operations, they occur with all types and can lead to death.
Health consequences of FGM seem to vary according to the type and severity of the procedure. Complications may range from immediate, such as bleeding and shock, to a wide range of longer-term problems for women and their newborn children. Psychological effects may be profound and permanent. Additionally, FGM may increase the risk of HIV or Hepatitis B, due to unclean conditions often associated with the procedure.
Global Efforts to Promote Alternatives to FGM Are Increasing
Efforts to promote alternatives to FGM are increasing worldwide. International health organizations and conventions have uniformly condemned the procedure. The 1994 Programme of Action of the International Conference on Population and Development (ICPD) included a recommendation to ". . . urgently take steps to stop the practice of female genital mutilation and to protect women and girls from all such similar unnecessary and dangerous practices." The 1995 Platform for Action of the Fourth World Conference on Women urged governments, international organizations, and nongovernmental groups "to develop policies and programmes to eliminate all forms of discrimination against the girl child, including female genital mutilation." FGM is recognized as a human rights violation in the U.S. State Department's annual country reports. In 1997 United Nations agencies (WHO, UNICEF, and UNFPA) issued a joint position paper and are increasing their efforts to eradicate FGM. RHO's Harmful Health Practices Links section provides more information about the statements of various human rights groups.
The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children (IAC) (www.iac-ciaf.ch/) with the collaboration of local NGOs has been advocating for elimination of FGM in more than 20 African countries. Technical assistance, advocacy, and funding for programs are being provided by various national and international development agencies. The United States Agency for International Development (USAID) has recently reviewed its FGM programming and increased its support for FGM elimination programs.
Countries with laws or regulations against FGM include Australia, Burkina Faso, Canada, Central African Republic, Cote d'Ivoire, Djibouti, Egypt, Ethiopia, Ghana, Guinea, Kenya, New Zealand, Norway, Senegal, Sweden, Tanzania, Togo, Uganda, the United Kingdom, and the United States. Existing laws against assault and child abuse cover FGM in many other countries. Governments that otherwise support FGM elimination include Benin, Cameroon, Eritrea, Gambia, Niger, and Sudan.
Preventing Harmful Practices: Using Communication to Improve Health
Past efforts to change harmful health practices often have failed to analyze their causes, instead citing "tradition" as the only reason for a practice. Reformers need to understand why people do what they do; only then can plans for change be formulated. As development expert Robert Chambers writes: "Social change flows from individual actions. By changing what they do, people move societies in new directions and themselves change. Big, simple solutions are tempting but full of risks. For most outsiders, most of the time, the soundest and best way forward is through innumerable small steps and tiny pushes . . . many small reversals then support each other and together build up toward a greater movement." (IIED 1992)
While Information, Education, and Communication (IEC) activities are an important impetus for behavior change, often they are not enough. More may be needed in a program's "recipe" to cause people to really change the way they behave. Thus, the field has evolved into the more broadly defined area of "Behavior Change Communication." The Annotated Bibliography summarizes various references on behavior change theories and practices.
Dry sex and vaginal drying: Harmful practices?
The use of herbs and other substances to dry and tighten the vagina for sexual intercourse is known as "dry sex." Dry sex practices have been identified in South Africa, Senegal, Zaire, Cameroon, Malawi, Zambia, Kenya, Zimbabwe, Nigeria, Saudi Arabia, Indonesia, Malaysia, Haiti, and Costa Rica (Kun 1998; Hull 2001). Rates of practice often are high: for example, in Zimbabwe, 80 percent of commercial sex workers interviewed, 93 percent of health clinic attendees, and 80 percent of nurses had used a drying agent at least once (Civic 1996).
Dry sex preparation can entail inserting herbal leaves or powders, commercial products (for example, toothpaste, antiseptics, or soap), ground stones, or cloth into the vagina either on a regular basis or before sexual intercourse. These substances may or may not be left in the vagina during intercourse (Sandala 1995; Sayagues 1998).
Women engage in these practices for many reasons, not always directly related to sexual intercourse. However, the common theme among practicing cultures is that dry sex practices create a vagina that is dry, tight, and heated—all desirable qualities for men in many countries. Wives express the need to please their husbands with dry sex in order to keep them from leaving and/or to minimize their number of girlfriends. Focus groups with men indicate this may often be the reality (Van de Wijgert 1999). Sex workers aim to please their clients with dry sex. Some women report that the experience of dry sex is pleasurable for women as well; others report the opposite (Civic 1998; Sandala 1995). Men sometimes report mixed feelings about the pleasures of dry sex—but may express a dislike of vaginal fluids that keeps them from considering other options (Ray 1996).
Cultural Beliefs
Cultural beliefs about the vagina and reproductive health play a role in dry sex practices. Within the Shona culture, for example, female vaginal fluids are considered unclean, and their removal often is seen as important to creating a clean environment for fertilization. By douching or using dry sex agents, women believe they are also strengthening the body, preventing reproductive disease, and toning pelvic muscles (Runganga 1995). In addition to drying out the vagina for sexual, hygienic, or artistic reasons, agents may be used to specifically prevent and treat sexually transmitted diseases and vaginal infections, itching, and discharge. Older sex workers in Nigeria use ground tobacco leaves for this purpose (Dallabetta 1995).
In addition to the physical effects, many women believe drying agents act as as an aphrodisiac that causes their partners to think about them often, and cause attraction (Sayagues 1998; Civic 1998). In some places, men also use aphrodisiacs in the form of similar herbs and commercial products. These may either be taken by mouth or applied directly to the penis (Ray 1996).
Virginity testing
An abandoned tradition is coming back into practice in South Africa: virginity testing for girls and boys. While apparently motivated by genuine concern about HIV/AIDS, sexually transmitted infections, and unwanted pregnancy, the practice can have serious repercussions as a result of its limited effectiveness in discerning virginity and the implications for girls who are tested.
Centered primarily in the KwaZula/Natal province, girls are tested by examination of their hymen (which may not be intact for reasons other than sexual intercourse—some girls, for example, are born without hymens). Workers at a rape counseling center reported seeing 40 girls over the course of a year who were brought in by their parents after they failed their virginity test. Some girls had been beaten by their parents as a result of the failed test (Daley 1999). Another danger lies in the common myth that AIDS can be cured by sexual intercourse with a virgin; "certification" of virginity can put girls at risk of sexual violence.
Boy's virginity testing may take the form of having to urinate, without using their hands, over a three foot high fence. Other "markers" of virginity may include the foreskin thickness, the pattern urine makes in sand, and even the softness of the back of the knee (McGreal 1999).
Sex-selective technologies
Traditionally, infant sex selection has ranged from the pregnant mother’s use of traditional medicine and spiritualism to the extreme of infanticide. In many societies son preference is pervasive, so a boy is often the desired gender. Since the late 1970s, modern technology has made sex selective abortions possible. While newer techniques allow sex selective fertilization through in vitro fertilization and artificial insemination, the use of ultrasound technology is by far the most commonly used method of sexing fetuses. These high-tech solutions to son preference have generated a complex controversy which incorporates issues of gender bias and empowerment, economics, technology, demographics and “population control,” safe abortion, law, medicine, and community influences.
Lessons learned
When assessing the health and human rights issues associated with a traditional health practice and when working toward changing practices, health professionals must be aware of the following issues:
Consider offering alternatives: A harmful practice often has strong cultural underpinnings. Therefore, individuals and communities may hesitate to sacrifice what is perceived as important, although they recognize a practice is harmful. Offering substitute activities or a modified version of the practice may be constructive. For example, while girls and their families in a region of Kenya were willing to forego FGM, they did not want to give up the joyful ceremonies, gift-giving, and educational opportunities that accompanied the practice. Therefore, alternative ceremonies have been designed by the communities with great success. For more information visit www.path.org/programs/p-chi/female_genital_mutilation.htm .
Understand the power balance: Is the recipient of the practice or custom in a lesser power position, socially, economically, ethnically, politically, or in some other way? An individual's status in the community clearly can influence efforts to change harmful practices. Lower economic status commonly leaves women especially vulnerable.
Children and young women need extra protection: Is the recipient of a harmful health practice a child? Children need to be protected, since they cannot protect themselves and cannot make mature decisions. Unfortunately, those performing harmful practices often are doing what they think is best for a child and therefore can't protect them. For example, FGM is usually performed on children and young women who have little understanding of what is going to happen or the controversy that surrounds it.
Consider informed consent: This issue is of great importance within many medical belief systems, as well as in the international human rights arena. Is the recipient an adult who is giving informed consent—that is, do recipients really understand the risks and benefits of the practice? Are they personally and freely deciding to undergo the procedure? This is especially difficult when a practice is so common that none of the involved parties (sometimes including the government) are genuinely aware of options and dangers. The question of informed consent is most problematic in relation to FGM for adult women. Thorough education programs and extensive counseling should be employed.
Respect a positive or "neutral" traditional practice: When health care providers respect a practice they know is not harmful, it helps create a positive relationship with the clients. For example, some hospitals on American Indian Reservations in the United States encourage visits to patients from their traditional healers. Conversely, in Viet Nam, some clients feel angered by the lack of provider respect for the local practice of rubbing a coin over an ill person's body.
Understand the details of the practice: Often it is difficult to understand the actual physical and mental health impact of a practice. For example, there is a worldwide debate on the necessity of male circumcision, which is performed for a variety of reasons in many places. Health professionals should collect as much information as possible about a practice in order to gain broad insight. A great deal of information is available on FGM, nutrition, maternal health, and child health, among others.
Involve all stakeholders in change efforts: Changing harmful health practices is a complex process that must involve all stakeholders, including community members who may request and provide the practice, religious groups that may be reluctant to speak out about the practice, health providers who in some ways may support the practice, and government officials who may not understand the impact of the practice.
