Stop female genital mutilation

Female genital mutilation (FGM), also known as female genital cutting (FGC) and female circumcision, is the ritual cutting or removal of some or all of the external female genitalia. The practice is found in Africa, Asia and the Middle East, and within communities from countries in which FGM is common. UNICEF estimated in 2016 that 200 million women living today in 30 countries—27 African countries, Indonesia, Iraqi Kurdistan and Yemen—have undergone the procedures.^[3]

Typically carried out by a traditional circumciser using a blade, FGM is conducted from days after birth to puberty and beyond. In half the countries for which national figures are available, most girls are cut before the age of five.^[5]Procedures differ according to the country or ethnic group. They include removal of the clitoral hood and clitoral glans; removal of the inner labia; and removal of the inner and outer labia and closure of the vulva. In this last procedure, known as infibulation, a small hole is left for the passage of urine and menstrual fluid; the vagina is opened for intercourse and opened further for childbirth.^[6]

The practice is rooted in gender inequality, attempts to control women’s sexuality, and ideas about purity, modesty and beauty. It is usually initiated and carried out by women, who see it as a source of honour, and who fear that failing to have their daughters and granddaughters cut will expose the girls to social exclusion.^[7] Health effects depend on the procedure. They can include recurrent infections, difficulty urinating and passing menstrual flow, chronic pain, the development of cysts, an inability to get pregnant, complications during childbirth, and fatal bleeding.^[6] There are no known health benefits.^[8]

There have been international efforts since the 1970s to persuade practitioners to abandon FGM, and since 2010 the United Nations has called upon healthcare providers to stop performing all forms of the procedure, including reinfibulation after childbirth and symbolic “nicking” of the clitoral hood.^[9] It has been outlawed or restricted in most of the countries in which it occurs, but the laws are poorly enforced. The opposition to the practice is not without its critics, particularly among anthropologists, who have raised difficult questions about cultural relativism and the universality of human rights.^[10]

Terminology

English

Until the 1980s FGM was widely known as female circumcision, implying an equivalence in severity with male circumcision.^[11] From 1929 the Kenya Missionary Council referred to it as the sexual mutilation of women, following the lead of Marion Scott Stevenson, a Church of Scotland missionary.^[12] References to the practice as mutilation increased throughout the 1970s.^[13] In 1975 Rose Oldfield Hayes, an American anthropologist, used the term female genital mutilation in the title of a paper,^[14] and four years later Fran Hosken, an Austrian-American feminist writer, called it mutilation in her influential The Hosken Report: Genital and Sexual Mutilation of Females.^[15][16]

The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children and the World Health Organization (WHO) began referring to it as female genital mutilation in 1990 and 1991 respectively.^[17] Other terms used include female genital cutting (FGC) and female genital mutilation/cutting (FGM/C), preferred by those who work with practitioners.^[13]

Local terms

The many variants of FGM are reflected in dozens of terms in countries where it is common.^[18] These often refer to purification. In the Bambara language, spoken mostly in Mali, FGM is known as bolokoli (“washing your hands”)^[19] and in the Igbo language in eastern Nigeria as isa aru or iwu aru (“having your bath”).^[a] A common Arabic term for purification has the root t-h-r, used for male and female circumcision (tahur and tahara).^[21] It is also known in Arabic as khafḍ or khifaḍ.^[22]

Communities may refer to only two forms of FGM: “pharaonic” for infibulation and sunna circumcision for everything else.^[23] Sunna means “path or way” in Arabic and refers to the tradition of Muhammad, although none of the procedures are required within Islam.^[22] The term infibulation derives from fibula, Latin for clasp; the Ancient Romans reportedly fastened clasps through the foreskins or labia of slaves to prevent sexual intercourse. The surgical infibulation of women came to be known as pharaonic circumcision in Sudan, but as Sudanese circumcision in Egypt.^[24] In Somalia it is known simply as qodob (“to sew up”).^[25]

Methods

The procedures are generally performed by a traditional circumciser (cutter or exciseuse) in the girls’ homes, with or without anaesthesia. The cutter is usually an older woman, but in communities where the male barber has assumed the role of health worker he will perform FGM too.^[26][b]

When traditional cutters are involved, non-sterile devices are likely to be used, including knives, razors, scissors, glass, sharpened rocks and fingernails.^[28]:491 According to a nurse in Uganda, quoted in 2007 in The Lancet, a cutter would use one knife on up to 30 girls at a time.^[29]

Health professionals are often involved in Egypt, Kenya, Indonesia and Sudan. In Egypt 77 percent of FGM procedures, and in Indonesia over 50 percent, were performed by medical professionals as of 2008 and 2016.^[30][3] Women in Egypt reported in 1995 that a local anaesthetic had been used on their daughters in 60 percent of cases, a general anaesthetic in 13 percent and neither in 25 percent (two percent were missing/don’t know).^[31]

Classification

Surveys, UN typology

The WHO, UNICEF and UNFPA issued a joint statement in 1997 defining FGM as “all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or other non-therapeutic reasons”.^[13] The procedures vary considerably according to ethnicity and individual practitioners. During a 1998 survey in Niger, women responded with over 50 different terms when asked what was done to them.^[18] Translation problems are compounded by the women’s confusion over which type of FGM they experienced, or even whether they experienced it.^[32] Several studies have suggested that survey responses are unreliable.^[c]

Standard questionnaires from United Nations bodies ask women whether they or their daughters have undergone the following: (1) cut, no flesh removed (pricking or symbolic circumcision); (2) cut, some flesh removed; (3) sewn closed; or (4) type not determined/unsure/doesn’t know.^[d] The most common procedures fall within the “cut, some flesh removed” category and involve complete or partial removal of the clitoral glans.^[36]

WHO Types I–II

The World Health Organization created a more detailed typology. Types I–III vary in how much tissue is removed (Type III is the UNICEF category “sewn closed”). Type IV describes miscellaneous procedures, including symbolic circumcision.^[37][38]

Type Ia (circumcision)^[39] involves removal of the clitoral hood only and is rarely performed alone.^[e] The more common procedure is Type Ib (clitoridectomy), the complete or partial removal of the clitoral glans (the visible tip of the clitoris) and clitoral hood.^[1][41] The circumciser pulls the clitoral glans with her thumb and index finger and cuts it off.^[f]

Type II (excision) is the complete or partial removal of the inner labia, with or without removal of the clitoral glans and outer labia. Type IIa is removal of the inner labia; IIb, removal of the clitoral glans and inner labia; and IIc, removal of the clitoral glans, inner and outer labia. Excision in French can refer to any form of FGM.^[1]

Type III

Type III (infibulation or pharaonic circumcision), the “sewn closed” category, involves the removal of the external genitalia and fusion of the wound. The inner and/or outer labia are cut away, with or without removal of the clitoral glans. Type IIIa is the removal and closure of the inner labia and IIIb the outer labia.^[g] The practice is found largely in Djibouti, Eritrea, Ethiopia, Somalia and Sudan (though not South Sudan) in northeast Africa. Estimates of numbers vary: according to one in 2008, over eight million women in Africa have experienced it.^[h] According to UNFPA in 2010, 20 percent of women with FGM have been infibulated.^[44]

Comfort Momoh, a specialist midwife, describes Type III: “[E]lderly women, relatives and friends secure the girl in the lithotomy position. A deep incision is made rapidly on either side from the root of the clitoris to the fourchette, and a single cut of the razor excises the clitoris and both the labia majora and labia minora.” Girls “may be pinned down so firmly that bones may fracture”.^[47] In Somalia the clitoral glans is removed and shown to the senior female relatives, who decide whether enough has been amputated. After this the labia are removed.^[48] The amputated parts might be placed in a pouch for the girl to wear.^[49]

A single hole of 2–3 mm is left for the passage of urine and menstrual fluid by inserting something, such as a twig, into the wound.^[i][50] The vulva is then closed with surgical thread, agave or acacia thorns, or covered with a poultice such as raw egg, herbs and sugar.^[28]:491[51] To help the tissue bond, the girl’s legs are tied together, often from hip to ankle; the bindings are usually loosened after a week and removed after two to six weeks.^[52][28]:491 The result is a “drum of skin extending across the [vaginal] orifice except for a small hole”, Momoh writes.^[47]

If the remaining hole is too large in the view of the girl’s family, the procedure is repeated. The vagina is opened for sexual intercourse, for the first time either by a midwife with a knife or by the woman’s husband with his penis. In some areas, including Somaliland, female relatives of the bride and groom might watch the opening of the vagina to check that the girl is a virgin.^[53] Psychologist Hanny Lightfoot-Klein interviewed hundreds of women and men in Sudan in the 1980s about sexual intercourse with Type III:

The penetration of the bride’s infibulation takes anywhere from 3 or 4 days to several months. Some men are unable to penetrate their wives at all (in my study over 15%), and the task is often accomplished by a midwife under conditions of great secrecy, since this reflects negatively on the man’s potency. Some who are unable to penetrate their wives manage to get them pregnant in spite of the infibulation, and the woman’s vaginal passage is then cut open to allow birth to take place. … Those men who do manage to penetrate their wives do so often, or perhaps always, with the help of the “little knife”. This creates a tear which they gradually rip more and more until the opening is sufficient to admit the penis.^[54]

The woman is opened further for childbirth and closed afterwards, a process known as defibulation (or deinfibulation) and reinfibulation. Reinfibulation can involve cutting the vagina again to restore the pinhole size of the first infibulation. This might be performed before marriage, and after childbirth, divorce and widowhood.^[j][55]

Type IV

The WHO defines Type IV as “[a]ll other harmful procedures to the female genitalia for non-medical purposes”, including pricking, piercing, incising, scraping and cauterization.^[1] It includes nicking of the clitoris (symbolic circumcision), burning or scarring the genitals, and introducing substances into the vagina to tighten it.^[57][58] Labia stretching is also categorized as Type IV.^[59] Common in southern and eastern Africa, the practice is supposed to enhance sexual pleasure for the man and add to the sense of a woman as a closed space. From the age of eight, girls are encouraged to stretch their inner labia using sticks and massage. Girls in Uganda are told they may have difficulty giving birth without stretched labia.^[k][61]

A definition of FGM from the WHO in 1995 included gishiri cutting and angurya cutting, found in Nigeria and Niger. These were removed from the WHO’s 2008 definition because of insufficient information about prevalence and consequences.^[62] Angurya cutting is excision of the hymen, usually performed seven days after birth. Gishiri cutting involves cutting the vagina’s front or back wall with a blade or penknife, performed in response to infertility, obstructed labour and other conditions. In a study by Nigerian physician Mairo Usman Mandara, over 30 percent of women with gishiri cuts were found to have vesicovaginal fistulae (holes that allow urine to seep into the vagina).^[63]

Complications

Short-term and late

FGM harms women’s physical and emotional health throughout their lives.^[64][65]:49 It has no known health benefits.^[8] The short-term and late complications depend on the type of FGM, whether the practitioner has had medical training, and whether they used antibiotics and sterilized or single-use surgical instruments. In the case of Type III, other factors include how small a hole was left for the passage of urine and menstrual blood, whether surgical thread was used instead of agave or acacia thorns, and whether the procedure was performed more than once (for example, to close an opening regarded as too wide or re-open one too small).^[6]

Common short-term complications include swelling, excessive bleeding, pain, urine retention and healing problems/wound infection. A 2015 systematic review of 56 studies that recorded immediate complications suggested that each of these occurred in more than one in ten girls and women undergoing any form of FGM, including symbolic nicking of the clitoris (Type IV), although the risks increased with Type III. The review also suggested that there was under-reporting.^[66] Other short-term complications include fatal bleeding, anaemia, urinary infection, septicaemia, tetanus, gangrene, necrotizing fasciitis (flesh-eating disease) and endometritis.^{[65]:49[67][6]} It is not known how many girls and women die as a result of the practice, because complications may not be recognized or reported. The practitioners’ use of shared instruments is thought to aid the transmission of hepatitis B, hepatitis C and HIV, although no epidemiological studies have shown this.^[65]:50

Late complications vary depending on the type of FGM.^[6] They include the formation of scars and keloids that lead to strictures and obstruction, epidermoid cysts that may become infected, and neuroma formation (growth of nerve tissue) involving nerves that supplied the clitoris.^{[28]:491–492[68]}

An infibulated girl may be left with an opening as small as 2–3 mm, which can cause prolonged, drop-by-drop urination, pain while urinating, and a feeling of needing to urinate all the time. Urine may collect underneath the scar, leaving the area under the skin constantly wet, which can lead to infection and the formation of small stones. The opening is larger in women who are sexually active or have given birth by vaginal delivery, but the urethra opening may still be obstructed by scar tissue. Vesicovaginal or rectovaginal fistulae can develop (holes that allow urine or faeces to seep into the vagina).^[6][69] This and other damage to the urethra and bladder can lead to infections and incontinence, pain during sexual intercourse and infertility.^{[28]:491–492}

Painful periods are common because of the obstruction to the menstrual flow, and blood can stagnate in the vagina and uterus. Complete obstruction of the vagina can result in hematocolpos and hematometra (where the vagina and uterus fill with menstrual blood).^[6] The swelling of the abdomen that results from the collection of fluid, together with the lack of menstruation, can lead to suspicion of pregnancy. Asma El Dareer, a Sudanese physician, reported in 1979 that a girl in Sudan with this condition was killed by her family.^[70]

Pregnancy, childbirth

FGM may place women at higher risk of problems during pregnancy and childbirth, which are more common with the more extensive FGM procedures.^[6] Infibulated women may try to make childbirth easier by eating less during pregnancy to reduce the baby’s size. ^[45]:99 In women with vesicovaginal or rectovaginal fistulae, it is difficult to obtain clear urine samples as part of prenatal care, making the diagnosis of conditions such as pre-eclampsia harder.^{[28]:491–492} Cervical evaluation during labour may be impeded and labour prolonged or obstructed. Third-degree laceration (tears), anal-sphincter damage and emergency caesarean section are more common in infibulated women.^[6][45]:97

Neonatal mortality is increased. The WHO estimated in 2006 that an additional 10–20 babies die per 1,000 deliveries as a result of FGM. The estimate was based on a study conducted on 28,393 women attending delivery wards at 28 obstetric centres in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan. In those settings all types of FGM were found to pose an increased risk of death to the baby: 15 percent higher for Type I, 32 percent for Type II and 55 percent for Type III. The reasons for this were unclear, but may be connected to genital and urinary tract infections and the presence of scar tissue. The researchers wrote that FGM was associated with an increased risk to the mother of damage to the perineum and excessive blood loss, as well as a need to resuscitate the baby, and stillbirth, perhaps because of a long second stage of labour.^[71][72]

Psychological effects, sexual function

According to a 2015 systematic review there is little high-quality information available on the psychological effects of FGM. Several small studies have concluded that women with FGM suffer from anxiety, depression and post-traumatic stress disorder.^[65]:50 Feelings of shame and betrayal can develop when women leave the culture that practises FGM and learn that their condition is not the norm, but within the practising culture they may view their FGM with pride, because for them it signifies beauty, respect for tradition, chastity and hygiene.^[6]

Studies on sexual function have also been small.^[65]:50 A 2013 meta-analysis of 15 studies involving 12,671 women from seven countries concluded that women with FGM were twice as likely to report no sexual desire and 52 percent more likely to report dyspareunia (painful sexual intercourse). One third reported reduced sexual feelings.^{[73][65]:51[74]}

Distribution

Household surveys

Aid agencies define the prevalence of FGM as the percentage of the 15–49 age group that has exerienced it.^[75] These figures are based on nationally representative household surveys known as Demographic and Health Surveys (DHS), developed by Macro International and funded mainly by the United States Agency for International Development (USAID), and Multiple Indicator Cluster Surveys (MICS) conducted with financial and technical help from UNICEF.^[32]

These surveys have been carried out in Africa, Asia, Latin America and elsewhere roughly every five years, since 1984 and 1995 respectively.^[76] The first to ask about FGM was the 1989–1990 DHS in northern Sudan. The first publication to estimate FGM prevalence based on DHS data (in seven countries) was by Dara Carr of Macro International in 1997.^[77]

Prevalence

FGM is found mostly in what Gerry Mackie called an “intriguingly contiguous” zone in Africa—east to west from Somalia to Senegal, and north to south from Egypt to Tanzania.^[78] Nationally representative figures are available for 27 countries in Africa, as well as Indonesia, Iraqi Kurdistan and Yemen. Over 200 million women and girls are thought to be living with FGM in those 30 countries.^[3][79]

The highest concentrations among the 15–49 age group are in Somalia (98 percent), Guinea (97 percent), Djibouti (93 percent), Egypt (91 percent) and Sierra Leone (90 percent).^[80] As of 2013, 27.2 million women had undergone FGM in Egypt, 23.8 million in Ethiopia, and 19.9 million in Nigeria.^[81] There is also a high concentration in Indonesia, where Type Ia (removal of the clitoral hood) and symbolic nicking (Type IV) are practised; the prevalence rate for the 0–11 group is 49 percent (13.4 million).^[3][79]:2

Smaller studies or anecdotal reports suggest that FGM is also practised in Colombia, the Congo, Malaysia, Oman, Peru, Saudi Arabia, Sri Lanka, and the United Arab Emirates, as well as among the Bedouin in Israel; in Rahmah, Jordan; and among the Dawoodi Bohra in India.^[3][82][83] It is also found within immigrant communities in Australasia, Europe, North America and Scandinavia.^[84]

Downward trend

Prevalence figures for the 15–19 age group and younger show a downward trend.^[l] For example, Burkina Faso fell from 89 percent (1980) to 58 percent (2010); Egypt from 97 percent (1985) to 70 percent (2015); and Kenya from 41 percent (1984) to 11 percent (2014).^[87]

From 2010 household surveys asked women about the FGM status of all their living daughters.^[88] The highest concentrations among girls aged 0–14 were in Gambia (56 percent), Mauritania (54 percent), Indonesia (49 percent for 0–11) and Guinea (46 percent).^[3] The figures suggest that a girl was one third less likely in 2014 to undergo FGM than she was 30 years ago.^[89] If the rate of decline continues, the number of girls cut will nevertheless rise from 3.6 million a year in 2013 to 4.1 million in 2050 because of population growth.^[m]

Rural areas, wealth, education

Surveys have found FGM to be more common in rural areas, less common in most countries among girls from the wealthiest homes, and (except in Sudan and Somalia) less common in girls whose mothers had access to primary or secondary/higher education. In Somalia and Sudan the situation was reversed: in Somalia the mothers’ access to secondary/higher education was accompanied by a rise in prevalence of FGM in their daughters, and in Sudan access to any education was accompanied by a rise.^[91]

Age conducted

FGM is not invariably a rite of passage between childhood and adulthood, but is often performed on much younger children.^[92] Girls are most commonly cut shortly after birth to age 15. In half the countries for which national figures were available in 2000–2010, most girls had been cut by age five.^[93] Over 80 percent (of those cut) are cut before the age of five in Nigeria, Mali, Eritrea, Ghana and Mauritania.^[94] The 1997 Demographic and Health Survey in Yemen found that 76 percent of girls had been cut within two weeks of birth.^[95] The percentage is reversed in Somalia, Egypt, Chad and the Central African Republic, where over 80 percent (of those cut) are cut between five and 14.^[94] Just as the type of FGM is often linked to ethnicity, so is the mean age. In Kenya, for example, the Kisi cut around age 10 and the Kamba at 16.^[96]

Ethnicity

A country’s national prevalence often reflects a high sub-national prevalence among certain ethnicities, rather than a widespread practice.^[97] In Iraq, for example, FGM is found mostly among the Kurds in Erbil (58 percent prevalence within age group 15–49, as of 2011), Sulaymaniyah (54 percent) and Kirkuk (20 percent), giving the country a national prevalence of eight percent.^[98] The practice is sometimes an ethnic marker, but may differ along national lines. In the northeastern regions of Ethiopia and Kenya, which share a border with Somalia, the Somali people practise FGM at around the same rate as they do in Somalia.^[99] But in Guinea all Fulani women responding to a survey in 2012 said they had experienced FGM,^[100] against 12 percent of the Fulani in Chad, while in Nigeria the Fulani are the only large ethnic group in the country not to practise it