Breast Ironing: A Harmful Practice That Spans Generations

The cocks crowed, signifying morning was nigh.
Hope shuddered as she thought of what awaited her.
Her developing breasts throbbed with excruciating pain, worsened hours ago when her mama had pounded them with hot stones.
She’d cried and pled as mama pounded and auntie held her, but it was useless.
They said they were doing it for her, they didn’t want the men to desire her, but Hope felt none of their love.
All she felt was the pain.
And she saw the scars she knew would never leave.
She heard mama’s footsteps. It was time.
This was her daily routine, one that began when she’d clocked nine and the breasts started to show.
She sobbed, wishing herself away from this hidden ritual.
No one could hear her, no one could save her.

Hope may not be real but what she suffered – breast ironing – is. This is the reality for many girls.

Breast ironing is an action perpetuated to stop the development of breasts. It is carried out by using hot objects like stones, paddles, spatulas, and brooms to massage, pound, and press the breasts flat. Sometimes, belts or bandages are used to bind the breasts. This act is usually carried out by mothers, female relatives, shamans and rarely, the victim.

I first came to know of this practice when I stumbled across a report by Aljazeera, detailing this cruel act that is ongoing within refugee communities in Ogoja, Nigeria – my country. The report explained that this act is carried out by refugee Cameroonian mothers because of the high levels of sexual harassment and assault to which female refugees are exposed. It is done in the hope that their daughters will become less desirable to men.

According to the United Nations, 3.8 million girls in the world today are affected by breast ironing.

Breast ironing culture, also known as breast flattening, is widespread in African countries like Cameroon, Guinea-Bissau, Chad, Benin, and Togo. It is most prevalent in Cameroon, with the number of girls who have been subjected to it estimated at around 1.3 million! However, it is not only prevalent in African countries. Came Women and Girls Development organization estimate that every year, 1000 girls aged 9-15 across the UK are victims of breast ironing!

The reasons behind the practice are meant to “protect” girls.

Mothers perform this act because they believe that no breasts will make their daughters less attractive to the opposite sex, thereby warding off sexual advances. These mothers ignore their daughters’ pain as they have the intention of “protecting” them from rape, sexual harassment, early marriage.

Nonetheless, it remains a misguided intention because breast ironing only exposes girls to extreme pain, psychological damage, infections, cancer, and inverted nipples.

What’s being done against breast ironing?

Breast ironing does not receive as much attention as it should. In Cameroon, where it is rampant, anti-breast ironing laws are non-existent. In the UK, it has been recognized as abuse within the Violence Against Women and Girls strategy. As of July 2019, The Crown Prosecution Service (CPS) has updated the So-Called Honour-Based Abuse and Forced Marriage guidance to recognize breast ironing as a criminal offense. Notwithstanding, to date there have been no prosecutions. This practice continues in secret and is difficult to detect.

While organizations exist that fight against this act, more still needs to be done.

We need to stop it now and save lives.

People need to understand that breast ironing is not capable of solving the larger problems. It is just a branch of a larger tree: gender inequality.

Girls should be seen as equals and taught to respect themselves. Women should understand that sexual abuse is not their fault but the perpetrator’s. This way we can wipe away the need for this practice. Sex education for mothers, children, families should also be integrated into the society.

Lacking restrictions against breast ironing is one of the reasons this practice festers.

The law has turned its face away and refuses to protect these girls. No more should we give the excuse of culture when millions are hurting. We have to start prosecuting perpetrators – this will serve as a deterrent and protect victims. Educators need to be alert for signs of breast ironing. Finding out early will be effective in saving girls.

Breast ironing is a global issue that we need to pay attention to. We should work towards affecting solutions and curing these inequalities that devalue women. Most importantly, we have to put an end to sexual violence, as this harmful practice was ignorantly borne as its solution. We have to stop hurting girls and go after perpetrators of this act and sexual abuse.

Girls Just Wanna Have Fun-damental Rights in Kenya

Imagine waking up one morning with a really bad flu. Your immediate recourse would be to take fluids and maybe some medication. Should a sore throat develop, you might take cough syrup or lozenges. Commonly here in Kenya, a ‘dawa’ (a hot drink of honey, ginger and lemon) might hit the spot. Now, imagine that the law requires you to acquire permission from your boyfriend, husband, parent, guardian, neighbour, religious and faith leader, Ministry of Health, County Governor or even your President to go into a pharmacy, health center or hospital to receive the healthcare you need.

This scenario seems intrusive, unfair and even irrational. What justification beguiles such restrictive control on your flu? You obviously know you have it, you know how and where to seek medical treatment and you understand which actions would help you recover. Despite this, you need permission from others before seeking medical attention.

This scenario, whilst metaphorical, represents many of the challenges encountered by women and girls in Kenya and elsewhere in Africa when it comes to their bodily autonomy. Specifically, when it comes to their access to comprehensive Sexual and Reproductive Health and Rights (SRHR).

Girls and young women bear the brunt of the unmet need for contraception in Kenya, resulting in almost a quarter of Kenyan women giving birth before they are 18. 

Restrictive abortion laws in the region have not translated into a reduction in the incidences of abortion. Instead, they have increased the magnitude of unsafe abortion – 3 out of every 4 abortions in Africa are unsafe. Here in Kenya, the Constitution provides for instances under which a woman can access safe and legal abortion services. Article 26(4) of the Constitution states that “abortion is not permitted except, in the opinion of a trained health professional, there is a need for emergency treatment, or the life or health of the mother is in danger, or if permitted by any other written law”.

Ultimately, women in Kenya are not trusted to seek their own sexual and reproductive health care. The decision to access safe abortion as espoused in the Constitution places the entire burden on the trained health professional – leaving no room for the woman’s right to access.

Moving from law to practice and implementation is a whole other ball game. Existing evidence attributes high levels of severe maternal health outcomes to adverse complications such as sepsis, cervical and uterine ruptures, haemorrhage and death – the ‘terrible 5’ as coined by Sexual and Reproductive Justice advocates in the country. In addition, these specific outcomes vary across the country. SRH services are devolved to county level, and so the quality of care you can access is a postcode lottery, depending on which of the 47 counties you happen to live in. For example, the proportion of women with high fertility risk ranges from 24% in Nairobi to 66% in Migori.

Fighting the barriers to good quality reproductive health care forms the crux of one of KELIN’s projects, funded by the Safe Abortion Action Fund.

The ultimate goal is to have model SRHR Laws developed to promote women’s right to access safe abortion in Kenya. The intervention targets counties of Kilifi and Nakuru. We engage local communities through community-centered and community-driven dialogues in a bid to empower them with knowledge of how to engage with their county’s legislative processes. This is intended to increase public participation in policy making and to strengthen and build community movements to monitor implementation and champion legal reform.

Ultimately, laws are intended to create social change, spur on reform and maintain social order. But this is dependent on how they are made, implemented and interpreted. Even if a law is considered ‘good’, with its spirit and intent seen to be in the right place, it does not necessarily translate to a ‘good’ outcome.

We at KELIN envision a country and a world where women and girls can make decisions and enjoy rights related to their sexual and reproductive health. This includes the right to access safe abortion. We want to make reproductive care as simple as getting flu medication at the pharmacy or seeing a doctor without barriers, judgement or condemnation.

 KELIN is a Safe Abortion Action Fund grantee partner.

The App Empowering Young Women in Uganda

In Uganda, young women and girls face many sexual and reproductive health and rights (SRHR) challenges. For example, a high unmet need for contraception leads to dire consequences like unplanned pregnancies and sexually transmitted infections.

Challenges that limit provision of SRHR services to adolescents and young women include lack of privacy and confidentiality, knowledge gaps, cultural and social stigma, biased service providers, and inconvenience in accessing SRHR services despite their availability. Although there have been improvements in creating a youth-attractive environment for SRHR services and access to tools, more work is needed.

We are constantly reminded of the need to provide avenues where young people – including women and girls – can access sexual and reproductive health and rights services that are equitable, appropriate and effective.

At Reach A Hand Uganda, we help to address this need through our youth empowerment centres, and now, we have introduced the SAUTIplus app.

The SAUTIplus app is an innovative part of the SAUTIplus ecosystem,  helping to fill existing gaps in information. Uganda is experiencing a smartphone boom, with over half the population now owning one, and this number is increasing day by day.

Internet penetration in Uganda is at 41.6% – with 19 million Ugandans connected to the internet. In 2017, the Uganda Communications Commission recorded that the total number of mobile phone subscriptions was 23,529,979, up from 21,039,690 the previous quarter.

The SAUTIplus app was revamped two months ago to further engage Uganda’s high youth population and, at the time of writing, has 1,600 downloads on Google Play Store. The iOS version is in its final stages of going live.

On the app, information is available day or night. With a few taps of their phone, young women and girls can quickly find answers to their burning questions about sexual and reproductive health.

It’s the young people at Reach a Hand Uganda producing the content for the app and answering the questions – with support from the Programs and Communications departments. We understand the needs of the young women and girls and can craft our responses to reach the users in a relatable manner.

Users are able to see answers to questions other young people have asked and read tailor-made stories addressing issues faced by girls. Questions can be submitted on the website (hopefully soon to be added to the app) and the questions and answers can be viewed on either the app or website. The questions can be anonymous to maintain a safe and confidential space.

The app provides accurate information on SRHR, rather than simply promoting abstinence, which has proven an ineffective method of protecting young girls in Uganda.

The section named ‘Senga’ is a reference to a trusted relationship between a woman and her father’s sister (auntie). This relationship is commonly one where information regarding sexual and reproductive health and rights is passed on, but there can be a gap in appropriate or accurate information. This is where the SAUTIplus app comes in.

‘Senga’ provides an opportunity to view answers to questions you may have had yourself, smashing the common myths and misconceptions surrounding SRHR in Uganda. “My boyfriend says we don’t need contraception because he will pull out at the last minute. Is this a good idea?” is an example of one of the questions asked by a young girl on Senga.

The SAUTIplus app is providing a platform for women and girls to take charge of their sexual health. The knowledge the app provides is giving power to young women.

With power comes increased agency and the ability to negotiate within relationships – for example, with regards to contraceptive use to prevent pregnancy. No topic is taboo on the app. This includes menstruation and menstrual hygiene, a key SRHR challenge Reach a Hand have identified among young women in the country.

The for-the-youth attitude of the SAUTIplus app means it is an engaging platform for young people to access reliable information. Multimedia content, including photos, videos and blogs, provide a plethora of youth-friendly, easily digestible resources on SRHR.

The app is in continuous development, striving to meet the changing needs of young women in Uganda. It aims to create a positive relationship between young people and SRHR information, showing that information is a tool of power and not something to be dismissed. 

Mental Health in India’s Adolescent Girls

At ten years old, at the delicate intersection of childhood and adolescence, I lost my father.

The sudden, swift loss of a loved one left my family with a vacuum that felt insurmountable. Fear, inordinate sadness and hopelessness enveloped our home. Our South Asian family was heavily steeped in cultural norms. Showing one’s wounds to others was viewed negatively.

Crying was looked down upon, and seeking help would be an impermissible acknowledgement of weakness. Therapy was not a word in our vocabulary.

As I was expected to, I placed invisible bandages over my pain and suffering. I walked to school one week later with a forced smile pasted on my face. When asked how I was feeling, I quickly redirected the conversation, replying, “I’m okay.”

This external reticence surrounding my feelings and emotions continued throughout my adolescent years. While I experienced intermittent jolts of sadness and depression – likely as result of all that I had concealed and bottled up – I never once considered the option of therapy.

Now, as a pediatrician, I recognize the need to end the stigma and silence surrounding mental health in South Asian communities.

I have seen again and again the multi-generational consequences of mental illness, particularly depression. I co-founded Girls Health Champions, a non-profit training adolescents as peer-to-peer health educators, because I have seen firsthand that young people have significant unmet needs surrounding mental and physical health.

We know from both anecdotal and empirical evidence that adolescent depression and mental illnesses are on the rise, specifically for young women. Girls are over three times more likely than boys to experience depressive symptoms. The extent and complexity of mental illness among youth in India continues to be understudied, and the support for young people is stagnant.

Our suicide rate is a public health crisis – India accounts for 36.6% of suicides globally. Additionally, among Indian women and teenage girls aged 15–19, suicide has surpassed maternal mortality as the leading cause of death.

We have ample evidence to show that frank discussion and dialogue must start early and occur frequently. However, addressing the mental health of adolescent girls requires a thoughtful, multi-pronged strategy.

We must address cultural attitudes when approaching girls’ mental health education.

We know that South Asians, including young people, share a cultural resistance towards legitimizing mental health as a medical need. According to Dr. Nidhi Kosla, a mental health provider, South Asians “fail to report their [emotional] pain to avoiding burdening others or being seen as weak.” This might explain why many South Asians do not utilize resources such as therapy or psychiatric care, even if they are aware of them.

Additionally, in India, mental illnesses such as depression have often been equated with words such as “pagal”, or crazy. This language intensifies the shame and stigma young people experience. As a result, discussions of mental health must not only focus on awareness raising, but also on addressing and overcoming prevalent stigmas.

Mental health remains an underdeveloped and understaffed field in India’s medical practice. It is time to start building India’s mental health infrastructure.

Out of the 936,000 doctors in India, there are only roughly 4,500 psychiatrists to serve a population of 1.3 billion. In comparison, the USA, with a population a quarter the size of India’s, has 7,000 psychiatrists of Indian origin and 28,000 overall. 

India’s mental health infrastructure is also severely limited, with only 43 government mental health hospitals across all of India to provide services for the estimated 70 million people living with psychosocial disabilities.

In addition, most general practitioners and pediatricians are not adequately trained in identifying or managing mental health illnesses. These are often the people who serve as the first medical ‘touch points’ for young girls. Many providers may even hold negative attitudes towards mental health conditions themselves. Investment in training for frontline health workers is essential.

In both my experiences as a pediatrician and with Girls Health Champions, I have learned that a majority of young girls do not feel they can turn to their parents when it comes to discussing mental health-related issues. 

Parents play a critical role in providing a supportive climate around mental health.

We must educate them to have understanding, empathy, and awareness of mental health-related issues. Parents should develop the capacity to identify potential issues in their children and recognize when it would be appropriate to seek help.

I want our young people to know that it is okay to feel, to reach out for help, or even to say, “I am not okay”.

Day after day, I diagnose young girls with mental illnesses, including depression. During these visits, we often talk about the importance of removing the invisible bandages. We talk about the fact that ultimately, opening up is a sign of strength.

Obstetric Fistula is a Physical & Mental Health Priority

“It’s been three years now, I can’t wear underwear, urine is always leaking. I have developed sores on my genitals that aren’t healing because of the moisture. I dread going out in public.

The last time I went to a gathering, people distanced themselves from me because of the bad smell. I repelled them. I’m confined to this house so I can bathe each time I soil myself. My entire family believes I was cursed, they say no one has ever had a disease like mine before.”

Nyaradzai is a 19-year-old living in my community in Mashonaland, Zimbabwe. She is one of many women suffering from obstetric fistula. 

Like many others, Nyaradzai has been unaware that hers is a condition that needs medical attention. She tells me her story:

“Three years ago, I dropped out of school. I was pregnant. My parents chased me from my home, so I went to stay at my boyfriend’s house. He was still in high school too, but his parents accepted me. I stayed there for six months. 

My baby died while I was in labour. It took me 6 hours to get to the nearest clinic – I was walking because my in-laws couldn’t afford to hire an ambulance to take me there. When I arrived, the nurses ignored me. In fact, they scolded me for getting pregnant at such a tender age. I was 16 at the time. While I was in labor, I passed out. I can’t recall what happened, but when I gained consciousness, I was in so much pain.

When my in-laws heard that I had delivered a stillborn baby, they called me a witch and returned me to my parents’ house. My problems started a few days later.

At first, I thought I just wasn’t making it to the toilet in time, but I was also wetting the bed at night. Now when I go to sleep I take a cloth and place it between my legs and put a plastic sheet underneath me so I won’t wet the bed. I can’t wear underwear because of the sores on my genitals.”

Nyaradzai’s story could be the story of many women living with fistula in Zimbabwe.

Fistula is a silent condition, and as a result many women are suffering in silence. Huge numbers of people are not aware of what it is or what it means for women.

A fistula is a passage or hole that has formed between two organs. Obstetric fistula is an abnormal opening that develops between the birth canal and the urinary tract. It is the primary type of fistula affecting women in developing countries.

Obstetric fistula is caused by lack of access to quality obstetric care, particularly prolonged and obstructed labour without treatment. Young girls can be at high risk, as their birth canals are still narrow. The head of the baby causes a tear between the birth canal and the bladder or rectum which, if not surgically repaired, leaves women incontinent.

2 million women in sub-Saharan Africa, Asia, the Arab region, and Latin America and the Caribbean are living with fistula. 

As Nyaradzai has experienced, the social isolation associated with physical symptoms can have significant mental health consequences. Obstetric fistula is almost entirely preventable, and its prevalence in the world is a sign that health systems are failing women.

I share Nyaradzai’s story today, on International Day to End Obstetric Fistula, to try to break the silence.  

It is important that we talk about fistula, teach communities about it and encourage women to help one another through education, empowerment and delaying marriage and child bearing.

Read more on girlsglobe.org and join the conversation online using #EndFistula.

The Impact of HIV on Adolescent Girls & Young Women

World AIDS Day celebrates its 30th anniversary this year with the theme of ‘Know Your Status’.

Great progress has been made since the first World AIDS Day in 1988 – 3 in 4 people living with HIV today know their status.

However, the work is not yet done – especially for women. Women account for more than half of the people living with HIV worldwide. In particular, adolescent girls (10-19 years) and young women (15-24 years) are significantly affected by HIV and have high prevalence rates.

In Eastern and Southern Africa, women make up 26% of new HIV infections despite making up only 10% of the population. Statistically, young women will acquire HIV five to seven years earlier than their male counterparts.

Why are women and girls at high risk of infection?

HIV disproportionately affects young women and girls because of their unequal social, cultural and economic status in society. These challenges include gender based violence, laws and policies that undermine women, and harmful cultural and traditional practices that reinforce stigma and the dynamic of male dominance.

Here some other reasons why gender inequality leaves women vulnerable to HIV:

  1. Lack of access to healthcare services – women encounter barriers to health services on individual, interpersonal, community and societal levels.
  2. Lack of access to education – studies show that educated girls and women are more likely to make safer decisions regarding sexual and reproductive health and have lower risk of partner violence.
  3. Poverty – an existing and overarching factor that increases the impact of HIV.
  4. Gender-based violence & intimate partner violence – these types of violence prevent young women from protecting themselves from HIV.
  5. ‘Blesser/Sugar Daddy’ culture and transactional sex – sex with older men for monetary or material benefits, exposes young women and girls to low condom use, unsafe sexual practices and increased rates of STIs.
  6. Child marriage – girls who marry as children are likely to be abused by their husbands and forced into sexual practices.
  7. Biological factors – adolescent girls are susceptible to higher rates of genital inflammation, which may increase the risk of HIV infection through vaginal intercourse.

Importance of HIV testing

HIV testing in young women and girls is essential. Many receive access to treatment and care services after testing. Some important determinants of testing are:

  • Going through antenatal care
  • Being married
  • Having primary and secondary education

We need to aim for more young women and girls to being tested so that they know their status, and can access adequate care and treatment services. HIV testing is necessary for expanding on treatment and ensuring that people with HIV have healthy, productive lives.

Addressing the Impact

To address the impact of HIV on young women and girls we need to have approaches and interventions that incorporate the diverse perspectives of women and girls. This is needed on all platforms from campaigning and policy-making to program design. As the World Health Organization recommends, a woman-centred approach that includes women as participants is required, so that our needs, rights and preferences are considered.

Better strategies are needed across all health system to improve accessibility, acceptability, affordability, uptake, equitable coverage, quality, effectiveness and efficiency of services, particularly for adolescent girls worldwide.