Language optionsSearch All WHO This site onlyMain navigation
Home
About WHO
Countries
Health topics
Publications
Data and statistics
Programmes and projects
Gender, women and health
Gender mainstreaming
Gender-based violence
Gender and HIV/AIDS
Gender and other health topics
Publications
Links
Gender in Regional Offices
Contact us
Gender, women and health
WHO > Programmes and projects > Gender, women and health
Main content Gender-based violence
ICRC/Nick Danziger
Gender-based violence, or violence against women (VAW), is a major public health and human rights problem throughout the world.
Violence against women has profound implications for health but is often ignored. WHO's World Report on Violence and Health notes that "one of the most common forms of violence against women is that performed by a husband or male partner.” This type of violence is frequently invisible since it happens behind closed doors, and effectively, when legal systems and cultural norms do not treat as a crime, but rather as a "private" family matter, or a normal part of life.
Priority work of GWH in VAW includes:
The WHO Multi-country Study on Women's Health and Domestic Violence Against Women
It is a landmark study, both in its scope and in how it was carried out. The report shows that violence against women is widespread with far-reaching health consequences. It calls on governments to take concerted action and makes recommendations for the health, education and criminal justice sectors to take the problem seriously.
This groundbreaking research has gathered comparable data from over 24,000 women interviewed in 15 sites in 10 countries: Bangladesh, Brazil, Ethiopia, Japan, Peru, Namibia, Samoa, Serbia and Montenegro, Thailand, and the United Republic of Tanzania.
:: Click here for full information
Sexual Violence
:: Click here for full information
Sexual Violence: Strengthening the Health Sector Response
Sexual violence is a pervasive global problem with significant health consequences for victims, yet in many places around the world, available services do not meet the needs of survivors.
This initiative includes the development of guidelines for providing care to sexual assault survivors and the development of a framework to guide health sector policies related to sexual violence.
:: Sexual Violence: Strengthening the Health Sector Response
The Sexual Violence Research Initiative (SVRI)
This initiative is designed to increase information about, awareness of, and capacity to address sexual violence around the globe, and particularly in the developing world. The Intiative's Secretariat is currently based in South Africa.
:: Click here for full information
Interaction of VAW and HIV
GWH highlights the intersections of violence against women and HIV/AIDS for annual campaigns such as the 16 Days of Activism against gender-based violence and World AIDS Days.
:: Click here for full information
WHAT'S NEW?
GWH Monthly update
:: July 2007 [doc 258kb]
:: Integrating gender analysis and actions into the work of WHO: draft strategy
10 facts about women's health
:: Click here
GWH New publications
:: New Publications
--------------------------------------------------------------------------------
EVENTS
:: International Women's Day (IWD) 2007 --Interagency panel: UN Action against Sexual Violence in Conflict
:: WHO Events
--------------------------------------------------------------------------------
FEATURED
:: WHO Multi-country Study on Women's Health and Domestic Violence against Women
:: WHO Ethical and safety recommendations for researching, documenting and monitoring sexual violence in emergencies [pdf 308kb]
:: Clinical Management of Rape Survivors: Developing protocols for use with refugees and internally displaced persons --Revised edition
:: Gender and Health in Disasters
--------------------------------------------------------------------------------
CONTACT US:
genderandhealth@who.int
Or at:
FCH/GWH
Batiment X
WHO
Avenue Appia 20
1211 Geneva 27
Switzerland
Fax: (41) 22 791 1585
Corporate linksE-mail scams | Employment | FAQs | Feedback | Other UN sites | Privacy | RSS feeds
© World Health Organization 2007. All rights reserved
Monday, 22 October 2007
Sunday, 21 October 2007
Tuesday, 16 October 2007
FGM Complete ingormation
HOME: POPULATION ISSUES: PROMOTING GENDER EQUALITY: FAQs on Female Genital Mutilation/Cutting
Empowering Women
Involving Men
Girls and Adolescents
Gender-based Violence
Harmful Practices
Female Genital Mutilation/Cutting
FAQs on Female Genital Mutilation/Cutting
Gender and HIV/AIDS
Women in Emergency Situations
Women's Rights in International Agreements
Additional Resources
State of World Population 2005: The Promise of Equality
Frequently Asked Questions on Female Genital Mutilation/Cutting
What is female genital mutilation/cutting (FGM/FGC)?
What are the different types of FGM/FGC?
Which type is the most common?
Different terms are used to describe FGM/FGC. What do they mean?
What is deinfibulation?
What is reinfibulation?
Where does the practice come from?
Who performs FGM/FGC?
What instruments are used to perform FGM/FGC?
What is done to stop the bleeding?
At what age is FGM/FGC performed?
In which countries is FGM/FGC practiced?
Why is FGM/FGC performed?
How many women and girls are affected?
How does FGM/FGC affect women’s health?
Is there a link between FGM/FGC and the risk of HIV/AIDS infection?
What are the psychological effects of FGM/FGC?
Is FGM/FGC required by certain religions?
Can FGM/FGC be condoned if it is carried out by medical professionals under hygienic circumstances?
Since FGM/FGC is part of a cultural tradition, can it still be condemned?
In which countries is FGM/FGC banned by law?
Which international legal instruments can be used for the eradication of FGM/FGC?
What terms do people who practice FGM/FGC use to describe the procedure?
What do women who underwent FGM/FGC have to say about it themselves?
What does the ICPD Programme of Action say about FGM/FGC?
What was said about FGM/FGC during the ICPD+5 review?
What is UNFPA’s approach to FGM/FGC?
Sources
What is Female Genital Mutilation/Cutting (FGM/FGC)?
FGC/FGM refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for cultural or other non-medical reasons.
top
What are the different types of FGM/FGC?
The World Health Organization (WHO) has identified four types:
Type 1:
Excision of the prepuce, with or without excision of part or all 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/narrowing of the vaginal opening (infibulation). Sometimes referred to as pharaonic circumcision.
Type 4:
Others, such as pricking, piercing or incising, stretching, burning of the clitoris, scraping of tissue surrounding the vaginal orifice, cutting of the vagina, introduction of corrosive substances or herbs into the vagina to cause bleeding or to tighten the opening.
top
Which type is the most common?
Types I and II are the most common, with variation among countries. Type III, infibulation, constitutes about 20 per cent of all affected women and is most likely in Somalia, northern Sudan and Djibouti.
top
Different terms are in use to describe FGM/FGC. What do they mean?
Incision:
refers to making cuts in the clitoris, cutting free the clitoral prepuce, but also relates to incisions made in the vaginal wall and to incision of the perineum and the symphysis.
Clitoridectomy:
refers to partial or total removal of the clitoris
Excision:
refers to the removal of the clitoris and partial or total removal of the labia minora. The amount of tissue that is removed varies widely from community to community.
Infibulation:
refers to the removal of the clitoris, partial or total removal of the labia minora and stitching together of the labia majora.
Circumcision:
this is a collective name that is used to describe a variety of practices involving the cutting of the female genitalia. It often refers to operations that fall under type I FGM/FGC. This term is considered as confusing by some since it seems to equate male circumcision with FGM/FGC. However, the only form that anatomically is comparable to male circumcision is that form in which the clitoral prepuce is cut away. This form seldom occurs. It is sometimes argued that the term circumcision obscures the serious physical and psychological effects of genital cutting on women.
Female genital mutilation:
this is also a collective name to describe procedures that involve partial or total removal of the external female genitalia or other injury to female genital organs whether for cultural or other non-medical reasons. This term is used by a wide range of women’s health and human rights organizations and activists, not just to describe the various forms but also to indicate that the practice is considered a mutilation of the female genitalia and as a violation of women’s basic human rights. Since 1994, the term has been used in several United Nations conference documents, and has served as a policy and advocacy tool.
Female genital cutting:
Some organizations have opted to use the more neutral term 'female genital cutting'. This stems from the fact that communities that practice FGC often find the use of the term 'mutilation' demeaning, since it seems to indicate malice on the part of parents or circumcisers. The use of judgmental terminology bears the risk of creating a backlash, thus possibly causing an alienation of communities that practice FGM/FGC or even causing an actual increase in the number of girls being subjected to FGM/FGC. In this respect it should be noted that the Special Rapporteur on Traditional Practices (ECOSOC, Commission on Human Rights) recently called for tact and patience regarding FGC eradication activities and warned against the dangers of demonizing cultures under cover of condemning practices harmful to women and girls.
top
What is de-infibulation?
Infibulation creates a physical barrier to sexual intercourse and childbirth. An infibulated woman therefore has to undergo gradual dilation of the vaginal opening before sexual intercourse can take place. Often, infibulated women are cut open on the first night of marriage (by the husband, or a circumciser), in order to enable the husband to be intimate with his wife. At childbirth, many women also have to be cut again, because the vaginal opening is too small to allow for the passage of a baby. Attempts at forcible penetration may cause rupture of scars and sometimes perineal tears, dyspareunia, and vaginismus. Excessive penile force during first intercourse can cause severe bleeding, shock and infection.
top
What is re-infibulation?
In some communities, the raw edges of the wound are sutured again after childbirth, recreating a small vaginal opening. This is referred to as re-infibulation.
top
Where does the practice come from?
The origins of the practice are unclear. It predates the rise of Christianity and Islam. There is mention made of Egyptian mummies that display characteristics of FGM/FGC. Historians such as Herodotus claim that in the fifth century BC the Phoenicians, the Hittites and the Ethiopians practised circumcision. It is also reported that circumcision rites were practised in tropical zones of Africa, in the Philippines, by certain tribes in the Upper Amazon, and in Australia by women of the Arunta tribe. It also occurred among the early Romans and Arabs. As recent as the 1950s, clitoridectomy was practised in Western Europe and the United States to treat 'ailments' in women as diverse as hysteria, epilepsy, mental disorders, masturbation, nymphomania, melancholia and lesbianism. In other words, the practice of FGM/FGC has been followed by many different peoples and societies across the ages and the continents.
top
Who performs FGM/FGC?
FGM/FGC is usually carried out by elderly people in the community (usually, but not exclusively, women) who have been specially designated for this task, or by traditional birth attendants. These people receive a fee from the girls’ family members, in money or in kind. In some cases, medical personnel perform the operation as well, for a fee. Among certain populations, FGM/FGC may be carried out by traditional health practitioners, (male) barbers, members of secret societies, herbalists, and sometimes by a female relative.
top
What instruments are used to perform FGM/FGC?
FGM/FGC is carried out with special knives, scissors, scalpels, pieces of glass or razor blades. Anaesthetic and antiseptics are not generally used except when carried out by medical practitioners. In communities where infibulations is practised, the girls’ legs are often bound together to immobilize her for a period of 10 – 14 days, to allow formation of scar tissue.
top
What is done to stop the bleeding?
Paste mixtures of local herbs, porridge, ashes, mud, earth etc. are rubbed on the wound to stop the bleeding. In the case of type 3 (infibulation) the sides of the wound are stitched, or held together by thorns (e.g. from acacia trees).
top
At what age is FGM/FGC performed?
The age at which FGM/FGC is performed varies. In some areas it is carried out during infancy (as early as a couple of days after birth), in others during childhood, at the time of marriage, during a woman’s first pregnancy or after the birth of her first child. The most typical age is 7 – 10 years or just before puberty, although reports suggest that the age is dropping in some areas.
top
In which countries is FGM/FGC practiced?
The practice is common in parts of Africa, Asia and in some Arab Countries. It is practiced among communities in : Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Cote d’Ivoire , Democratic Republic of Congo, Djibouti, Egypt, Ethiopia, Eritrea, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, Somalia, Sudan, Tanzania, Togo, Uganda.
FGM/FGC is also practiced among certain ethnic groups in a number of Asian countries (India, Indonesia, Malaysia, Pakistan); among some groups in the Arabian Peninsula (in Oman, Saudi Arabia, United Arab Emirates, Yemen); and among certain immigrant communities in Europe, Australia, Canada and the United States.
top
Why is FGM/FGC performed?
Cultural practices such as FGM/FGC are rooted in a set of beliefs, values, cultural and social behaviour patterns that govern the lives of people in society. There are many reasons given for practicing FGM/FGC. These can be categorised under five headings:
Psychosexual reasons:
FGM/FGC is carried out as a means to control women’s sexuality (which is argued to be insatiable if parts of the genitalia, especially the clitoris, are not removed). It is thought to ensure virginity before and fidelity after marriage and/or to increase male sexual pleasure.
Sociological and cultural reasons:
FGM/FGC is seen as part of a girl’s initiation into womanhood and as an intrinsic part of a community’s cultural heritage/tradition. Various myths exist about female genitalia (e.g. that if uncut the clitoris will grow to the size of a penis; FGM/FGC would enhance fertility or promote child survival, etc) and these serve to perpetuate the practice.
Hygiene and aesthetic reasons:
In some communities, the external female genitalia are considered dirty and ugly and are removed ostensibly to promote hygiene and aesthetic appeal.
Religious reasons:
Although FGM/FGC is not sanctioned by either Islam nor by Christianity, supposed religious prescripts (e.g. the mention of ‘Sunna” in the Koran) are often used to justify the practice.
Socio-economic factors:
In many communities, FGM/FGC is a prerequisite for marriage. Where women are largely dependent on men, economic necessity can be a major determinant to undergo the procedure. FGM/FGC sometimes is a prerequisite for the right to inherit. FGM/FGC may also be a major income source for circumcisers.
top
How many women and girls are affected?
It is estimated that over 130 million girls and women have undergone some form of genital mutilation/cutting, and at least 2 million girls are at risk of undergoing the practice every year.
top
How does FGM/FGC affect women’s health?
The effects of FGM/FGC depend on the type performed, the expertise of the circumciser, the hygienic conditions under which it is conducted, the amount of resistance and general health condition of the girl/woman undergoing the procedure. Complications may occur in all types of FGM/FGC, but are most frequent with infibulation.
FGM/FGC has both immediate and long-term consequences to the health of women.
Immediate complications:
These include severe pain, shock, haemorrhage, tetanus or infection, urine retention, ulceration of the genital region and injury to adjacent tissue, wound infection, urinary infection, fever and septicaemia. Haemorrhage and infection can be of such magnitude as to cause death.
Long term consequences:
These include anemia, the formation of cysts and abscesses, keloid scar formation, damage to the urethra resulting in urinary incontinence, dyspareunia (painful sexual intercourse) and sexual dysfunction, hypersensitivity of the genital area. Infibulation can cause severe scar formation, difficulty in urinating, menstrual disorders, recurrent bladder and urinary tract infection, fistulae, prolonged and obstructed labour (sometimes resulting in fetal death and vesico-vaginal fistulae and/or vesico-rectal fistulae), and infertility (as a consequence of earlier infections). Cutting of the scar tissue is sometimes necessary to facilitate sexual intercourse and/or childbirth. Almost complete vaginal obstruction may occur, resulting in accumulation of menstrual flow in the vagina and uterus. During childbirth the risk of hemorrhage and infection is greatly increased.
top
Is there a link between FGM/FGC and the risk of HIV/AIDS infection?
Because the procedure is coupled with the loss of blood and use is often made of one instrument for a number of operations, the risk of HIV/AIDS transmission is increased by the practice. Also, due to damage to the female sexual organs, sexual intercourse can result in lacerations of tissues, which greatly increases risk of transmission. The same is true for childbirth and subsequent loss of blood.
top
What are the psychological effects of FGM/FGC?
Genital mutilation/cutting may leave a lasting mark on the life and mind of the woman who has undergone the procedure. The psychological stress may trigger behavioural disturbances in children, closely linked to the loss of trust and confidence in care-givers. In the longer term, women may suffer feelings of anxiety, depression, and frigidity. Sexual dysfunction may also be the cause for marital conflicts and eventual divorce.
top
Is FGM/FGC required by certain religions?
No. The practice of FGM/FGC is not prescribed by Islam, nor in the Bible. In fact, the practice predates Islam, and many religious leaders have denounced it. The practice cuts across religions and is practiced by Muslims, Christians, Ethiopian Jews, Copts, as well as by followers of certain traditional African religions. FGM/FGC is thus more a cultural than a religious practice.
top
Can FGM/FGC be condoned if it is carried out by medical professionals under hygienic circumstances?
No. FGM/FGC in any form should not be practised by health professionals in any setting – including hospitals or other health establishments. Unnecessary bodily mutilation cannot be condoned by health providers. FGM/FGC is harmful to the health of women and girls and violates their basic human rights and medicalization of the procedure does not eliminate this harm. On the contrary, it reinforces the continuation of the practice by seeming to legitimize it. Health practitioners should provide all necessary care and counseling for complications that may arise as a result of FGM/FGC.
top
Since FGM/FGC is part of a cultural tradition, can it still be condemned?
Yes. The function of culture and tradition is to provide a framework for human well-being; cultural arguments can never be used to condone violence against persons, male or female. Moreover, culture is not static, but constantly changing and adapting. Nevertheless, activities for the elimination of FGM/FGC should be developed and implemented in a way that is sensitive to the cultural and social background of the communities that practice it. Behaviour can change when people understand the hazards of certain practices and when they realize that it is possible to give up harmful practices without giving up meaningful aspects of their culture.
top
In which countries is FGM/FGC banned by law?
Africa:
Benin, Burkina Faso, Central African Republic, Chad, Cote d’Ivoire, Djibouti, Egypt (Ministerial decree), Ghana, Guinea, Kenya, Niger, Nigeria (multiple states), Senegal, Tanzania, Togo. In Sudan only the most severe form of FGM/FGC is forbidden by law.
Others:
Australia, Belgium, Canada, Denmark, New Zealand, Norway, Spain, Sweden, United Kingdom, United States (federal law, and specific state laws).
Penalties range from a minimum of six months to a maximum of life in prison. Several countries also include monetary fines in the penalty. As of June 2000, there have been prosecutions or arrests in Burkina Faso, Egypt, Ghana, France and Senegal. Belgium. Benin, Nigeria, and Uganda are proposing laws to ban the practice of FGM/FGC.
In September 2001, the European Parliament adopted a resolution on Female Genital Mutilation . The resolution calls on the member states of the European Union to pursue, protect and punish any resident who has committed the crime of FGM even if committed outside the frontier ("extraterritoriality") and calls on the Commission and the Council to take measures in regard to the issuing of residence permits and protection for the victims of the practice. The resolution also calls on the member states to recognise the right to asylum of women and girls at risk of being subject to FGM/FGC.
top
Which international and regional instruments can be used for FGM/FGC eradication?
Most governments in countries where FGM/FGC is practised have ratified international conventions and declarations that make provisions for the promotion and protection of the health of women and girls. These include, inter alia:
1948
The Universal Declaration of Human Rights proclaims the right of all human beings to live in conditions that enable them to enjoy good health and health care (art. 25).
1966
The International Covenants on Civil and Political Rights and on Economic, Social and Cultural Rights condemn discrimination on the grounds of sex, and recognize the universal right to the highest attainable standard of physical and mental health (art. 12).
1979
The Convention on the Elimination of All Forms of Discrimination against Women requires State Parties to : “take all appropriate measure to modify or abolish customs and practices which constitute discrimination against women “ (art. 2f). “modify social and cultural patterns of conduct of men and women, with a view to achieving the elimination of prejudices and customary and all other practices which are based on the idea of the inferiority or the superiority of either of the sexes” (art 5a).
General recommendation 24 (1999) to article 12 of the Convention (on women and health) emphasizes that certain cultural or traditional practices such as FGM/FGC carry a high risk of death and disability and recommends that State parties should ensure the enactment and effective enforcement of laws that prohibit FGM/FGC.
General recommendation 14 (1990) pertains particularly to FGM/FGC. It recommends that State parties take appropriate and effective measures to eradicate female circumcision; to collect and disseminate basic data on traditional practices; to support women’s organization at the national and local levels that work for the elimination of harmful practices; to encourage politicians, professionals, religious and community leaders to co-operate in influencing attitudes; to introduce appropriate educational and training programmes; to include appropriate strategies aimed at eradication of female circumcision into national health policies; to invite assistance, information and advice from the appropriate organization of the United Nations system; to include in their reports to the Committee under articles 10 and 12 of the Convention information about measures taken to eliminate female circumcision.
1989
The Convention on the Rights of the Child protects against all forms of mental and physical violence and maltreatment (art 19.1); to freedom from torture or cruel, inhuman or degrading treatment (art 37a), and requires States to take all effective and appropriate measures to abolish traditional practices prejudicial to the health of children (art 24.3)
1993
The Vienna Declaration and the Programme of Action of the World Conference on Human Rights expanded the international human rights agenda to include gender-based violence including FGM/FGC.
1994
The Programme of Action of the International Conference on Population and Development.
1995
The Platform for Action of the Fourth World Conference on Women includes a section on the girl child and urges governments, international organization and non-governmental groups to develop policies and programmes to eliminate all forms of discrimination against the girl child, including female genital cutting.
1997
The African Charter on Human and Peoples’ Rights, article 4 on integrity of the person, article 5 on human dignity and protection against degradation, article 16 on the right to health, article 18 (3) on protection of the rights of women and children.
The Addis Ababa Declaration. At the Council of Ministers during its sixty-eighth Session in July 1998, the Organization of African Unity (OAU) adopted the Addis Ababa Declaration on violence against Women. This Declaration was later endorsed by the Assembly of heads of State and Governments. The Declaration serves as an important step towards the formulation of an African charter on violence against women, providing the framework for national laws against FGM/FGC.
1998
The Banjul Declaration. The Inter-African committee on Traditional Practices Affecting the Health of Women and Children in collaboration with the Gambian committee on Traditional Practices (GAMCOTRAP) organized a symposium for religious leaders and medical personnel in Banjul, Gambia, from 20 to 24 July 1998. Participants agreed that FGM/FGC is not prescribed by any religion and unequivocally condemned the use of religion to justify the practice, emphasizing the importance of information campaigns to put and end to them. At the close of the symposium they issued a communique, a declaration and recommendations condemning and demanding eradication of FGM/FGC and other harmful traditional practices.
1999
The United Nations Social, Humanitarian and Cultural Committee (Third Committee of the General Assembly) approved a resolution that calls upon States to implement national legislation and policies that prohibit traditional or customary practices affecting the health of women and girls, including FGM/FGC. It also calls upon States to prosecute perpetrators of practices that negatively affect the health of women and girls, and to intensify efforts to raise awareness and mobilize international and national opinion on the harmful effects of such practices.
The Ouagadougou Declaration. A workshop on concerted action against the practice of FGM/FGC in the West African Economic and Monetary Union (UEMOA) was organized in Ouagadougou from 4 to 6 May 1999. Participants made three recommendations : a) the preparation of an African charter on FGM/FGC; b) the adoption of specific legislation against FGM/FGC in all UEMOA States and ratification by these of regional and international instruments relating to the protection of women and girls; and c) the establishment of sub-regional networks of traditional and religious leaders and modern and traditional communicators to support the national committees in their campaign against FGM/FGC. A declaration known as the Declaration of Ouagadougou was adopted at the end of the workshop.
Key Actions for the Further Implementation of the Programme of Action of the International Conference on Population and Development. It calls for governments to promote human rights of women and girls and freedom from coercion, discrimination, violence, including harmful practice, and sexual exploitation and to review national legislation and amend those that discriminate against women and girls. It also calls for governments to ensure supervision of health providers to make sure that they are knowledgeable and trained to serve clients who have been subjected to harmful practice.
2000
Further Actions and Initiatives to Implement the Beijing Declaration and Platform for Action. While it recognses the progress made in the national legislation process to ban the practice of FGM/FGC, it points out that discriminatory attitudes and norms persist that makes girls and women more vulnerable to gender-based violence including FGM/FGC. It calls for national governments’ actions to combat and eliminate violence against women that are incompatible with the dignity and worth of the person.
top
What terms do people who practice FGM/FGC use to describe the procedure?
Since FGM/FGC is practiced in different countries and cuts across ethnic groups, there are many different names used to describe different forms of FGM/FGC. For instance:
Sunna: Sunna means ‘precept’ or ‘tradition’ in Arabic and it refers to a range of practices that follow the teachings of Islam. It is used in various communities to refer to different types of FGM/FGC, varying from incisions in the clitoris to intermediate forms. References to the term ‘sunna’ in the Koran are often used to justify FGM/FGC as being a religious obligation.
top
What do women who underwent FGM/FGC have to say about it themselves?
In the following quotation Zainab (22) tells us that she was infibulated at the age of 8:
“My two sisters, myself and our mother went to visit our family back home. I assumed we were going for a holiday. A bit later they told us that we were going to be infibulated. The day before our operation was due to take place, another girl was infibulated and she died because of the operation. We were so scared and didn’t want to suffer the same fate. But our parents told us it was an obligation, so we went. We fought back; we really thought we were going to die because of the pain. You have one woman holding your mouth so you won’t scream, two holding your chest and the other two holding your legs. After we were infibulated, we had rope tied across our legs so it was like we had to learn to walk again. We had to try to go to the toilet, if you couldn’t pass water in the next 10 days something was wrong. We were lucky, I suppose, we gradually recovered and didn’t die like the other girl. But the memory and the pain never really goes”. (WHO)
Do you want to know more?
Some useful links to other sites on FGM/FGC: Rainbo, at www.rainbo.org, PATH, at www.path.org, WHO, at www.who.org
top
What does the ICPD Programme of Action say about FGM/FGC?
The Programme of Action of the International Conference on Population and Development recognizes that violence against women is a widespread phenomenon. It states that : “In a number of countries, harmful practices meant to control women’s sexuality have led to great suffering. Among them is the practice of female genital cutting, which is a violation of basic rights and a major lifelong risk to women’s health (para 7.35).
The Programme of Action urges “Governments and communities (to)… urgently take steps to stop the practice of female genital cutting and protect women and girls from all such similar unnecessary and dangerous practices. Steps to eliminate the practice should include strong community outreach programmes involving village and religious leaders, education and counseling about its impact on girls’ and women’s health, and appropriate treatment and rehabilitation for girls and women who have suffered cutting. Services should include counseling for women and men to discourage the practice.” (para 7.40)
In Chapter 4 (Gender Equality, Equity and Empowerment of Women) the following paragraphs pertain to FGM/FGC:
Para 4.4: “Countries should act to empower women and should take steps to eliminate inequalities between men and women as soon as possibly by :
c) Eliminating all practices that discriminate against women; assisting women to establish and realize their rights, including those that relate to reproductive and sexual health”.
Para 4.9: “Countries should take full measure to eliminate all forms of exploitation, abuse, harassment and violence against women, adolescents and children”.
top
What was said about FGC/FGC during the ICPD+5 review?
The Report of the Ad Hoc Committee of the Whole of the Twenty-first Special Session of the General Assembly, indicates key actions for the further implementation of the Programme of Action of the International Conference on Population and Development. It states that :
Para 42: “Governments should promote and protect the human rights of the girl child and young women, which include economic and social rights as well as freedom from coercion, discrimination and violence, including harmful practices and sexual exploitation.”
Para 43: “Governments and civil society should take actions to eliminate attitudes and practices that discriminate against and subordinate girls and women and that reinforce gender inequality.”
Para 48: “Governments should give priority to developing programmes and policies that foster norms and attitudes of zero tolerance for harmful and discriminatory attitudes, including son preference, which can result in harmful and unethical practices such as prenatal sex selection, discrimination and violence against the girl child and all forms of violence against women, including female genital mutilation, rape, incest, trafficking, sexual violence and exploitation.”
Para 52 f: “Governments, in collaboration with civil society, including non-governmental organizations, donors and the United Nations system, should : Ensure that sexual and reproductive health programmes, free of any coercion, provide pre-service and in-service training and supervision for al levels of health-care providers to ensure that they maintain high technical standards, including for hygiene; respect the human rights of the people they serve; are knowledgeable and trained to serve clients who have been subjected to harmful practices, such as female genital mutilation and sexual violence…”
Para 52 g: “Promote men’s understanding of their roles and responsibilities with regard to respecting the human rights of women; …… and promoting the elimination of harmful practices, such as female genital mutilation, and sexual and other gender-based violence, ensuring that girls and women are free from coercion and violence.”
top
What is UNFPA’s approach to FGM/FGC?
UNFPA addresses the practice of FGM/FGC not only because of its harmful impact on the reproductive and sexual health of women, but also because it is a violation of women’s fundamental human rights. The basis for a rights approach is the affirmation that human well-being and health is influenced by the way a person is valued, respected and given the choice to decide on the direction of her/his life without discrimination, coercion or neglect of attention. UNFPA addresses FGM/FGC in a holistic manner, within its cultural and religious context; however cultural arguments can not be used to condone harmful practices such as FGM/FGC.
top
Sources for FAQs on Female Genital Mutilation/Cutting
“Female Genital Mutilation. A Joint WHO/UNICEF/UNFPA Statement.” 1997
“Female Genital Mutilation: The Practice.” WHO Information Package. 1994
“Visions and Discussions on Genital Mutilation of Girls. An International Survey.” Jacqueline Smith, 1995.
“Caring for women with circumcision. A technical manual for healthcare providers.” Nahid Toubia, Rainbo, 1999
“Socio-cultural aspects of female genital cutting.” M. de Bruyn, KIT, 1998.
“Medical aspects of female genital mutilation.” E. Leye, K. Roelens, M. Temmerman. International Center for Reproductive Health, University of Gent. 1998 CRLP Factsheet on FGC
“s Lands wijs, ‘s lands eer? Vrouwenbesnijdenis en Somalische vrouwen in Nederland”. K. Bartels and I. Haaijer, 1992
“FGC management during pregnancy, childbirth and post-partum period.”. Background paper for WHO Consultation, 15-17 October 1997, Geveva. Prof. H. Rushwan.
“Learning about social change. A research and evaluation guidebook using female circumcision as a case study”. S. Izett, N. Toubia. Rainbo 1999
“Towards the Eradication of Female Genital Mutilation in Egypt”. M. Hekmati, 1999
ECOSOC document E/CN.4/Sub.2/1999/14 : “Third report on the situation regarding the elimination of traditional practices affecting the health of women and the girl child”, by Ms. Halima Embarek Warzazi, pursuant to sub-commission resolution 1998/16
General Assembly document A/54/34 : “Traditional or customary practices affecting the health of women”. Report of the Secretary-General
General Assembly document A/C.3/54/C.13 : “Traditional or customary practices affecting the health of women and girls”.
top
| Contact Us | Help/FAQs | Site Index | Other UN Sites | Terms & Conditions | Fraud - Hotline |
Empowering Women
Involving Men
Girls and Adolescents
Gender-based Violence
Harmful Practices
Female Genital Mutilation/Cutting
FAQs on Female Genital Mutilation/Cutting
Gender and HIV/AIDS
Women in Emergency Situations
Women's Rights in International Agreements
Additional Resources
State of World Population 2005: The Promise of Equality
Frequently Asked Questions on Female Genital Mutilation/Cutting
What is female genital mutilation/cutting (FGM/FGC)?
What are the different types of FGM/FGC?
Which type is the most common?
Different terms are used to describe FGM/FGC. What do they mean?
What is deinfibulation?
What is reinfibulation?
Where does the practice come from?
Who performs FGM/FGC?
What instruments are used to perform FGM/FGC?
What is done to stop the bleeding?
At what age is FGM/FGC performed?
In which countries is FGM/FGC practiced?
Why is FGM/FGC performed?
How many women and girls are affected?
How does FGM/FGC affect women’s health?
Is there a link between FGM/FGC and the risk of HIV/AIDS infection?
What are the psychological effects of FGM/FGC?
Is FGM/FGC required by certain religions?
Can FGM/FGC be condoned if it is carried out by medical professionals under hygienic circumstances?
Since FGM/FGC is part of a cultural tradition, can it still be condemned?
In which countries is FGM/FGC banned by law?
Which international legal instruments can be used for the eradication of FGM/FGC?
What terms do people who practice FGM/FGC use to describe the procedure?
What do women who underwent FGM/FGC have to say about it themselves?
What does the ICPD Programme of Action say about FGM/FGC?
What was said about FGM/FGC during the ICPD+5 review?
What is UNFPA’s approach to FGM/FGC?
Sources
What is Female Genital Mutilation/Cutting (FGM/FGC)?
FGC/FGM refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for cultural or other non-medical reasons.
top
What are the different types of FGM/FGC?
The World Health Organization (WHO) has identified four types:
Type 1:
Excision of the prepuce, with or without excision of part or all 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/narrowing of the vaginal opening (infibulation). Sometimes referred to as pharaonic circumcision.
Type 4:
Others, such as pricking, piercing or incising, stretching, burning of the clitoris, scraping of tissue surrounding the vaginal orifice, cutting of the vagina, introduction of corrosive substances or herbs into the vagina to cause bleeding or to tighten the opening.
top
Which type is the most common?
Types I and II are the most common, with variation among countries. Type III, infibulation, constitutes about 20 per cent of all affected women and is most likely in Somalia, northern Sudan and Djibouti.
top
Different terms are in use to describe FGM/FGC. What do they mean?
Incision:
refers to making cuts in the clitoris, cutting free the clitoral prepuce, but also relates to incisions made in the vaginal wall and to incision of the perineum and the symphysis.
Clitoridectomy:
refers to partial or total removal of the clitoris
Excision:
refers to the removal of the clitoris and partial or total removal of the labia minora. The amount of tissue that is removed varies widely from community to community.
Infibulation:
refers to the removal of the clitoris, partial or total removal of the labia minora and stitching together of the labia majora.
Circumcision:
this is a collective name that is used to describe a variety of practices involving the cutting of the female genitalia. It often refers to operations that fall under type I FGM/FGC. This term is considered as confusing by some since it seems to equate male circumcision with FGM/FGC. However, the only form that anatomically is comparable to male circumcision is that form in which the clitoral prepuce is cut away. This form seldom occurs. It is sometimes argued that the term circumcision obscures the serious physical and psychological effects of genital cutting on women.
Female genital mutilation:
this is also a collective name to describe procedures that involve partial or total removal of the external female genitalia or other injury to female genital organs whether for cultural or other non-medical reasons. This term is used by a wide range of women’s health and human rights organizations and activists, not just to describe the various forms but also to indicate that the practice is considered a mutilation of the female genitalia and as a violation of women’s basic human rights. Since 1994, the term has been used in several United Nations conference documents, and has served as a policy and advocacy tool.
Female genital cutting:
Some organizations have opted to use the more neutral term 'female genital cutting'. This stems from the fact that communities that practice FGC often find the use of the term 'mutilation' demeaning, since it seems to indicate malice on the part of parents or circumcisers. The use of judgmental terminology bears the risk of creating a backlash, thus possibly causing an alienation of communities that practice FGM/FGC or even causing an actual increase in the number of girls being subjected to FGM/FGC. In this respect it should be noted that the Special Rapporteur on Traditional Practices (ECOSOC, Commission on Human Rights) recently called for tact and patience regarding FGC eradication activities and warned against the dangers of demonizing cultures under cover of condemning practices harmful to women and girls.
top
What is de-infibulation?
Infibulation creates a physical barrier to sexual intercourse and childbirth. An infibulated woman therefore has to undergo gradual dilation of the vaginal opening before sexual intercourse can take place. Often, infibulated women are cut open on the first night of marriage (by the husband, or a circumciser), in order to enable the husband to be intimate with his wife. At childbirth, many women also have to be cut again, because the vaginal opening is too small to allow for the passage of a baby. Attempts at forcible penetration may cause rupture of scars and sometimes perineal tears, dyspareunia, and vaginismus. Excessive penile force during first intercourse can cause severe bleeding, shock and infection.
top
What is re-infibulation?
In some communities, the raw edges of the wound are sutured again after childbirth, recreating a small vaginal opening. This is referred to as re-infibulation.
top
Where does the practice come from?
The origins of the practice are unclear. It predates the rise of Christianity and Islam. There is mention made of Egyptian mummies that display characteristics of FGM/FGC. Historians such as Herodotus claim that in the fifth century BC the Phoenicians, the Hittites and the Ethiopians practised circumcision. It is also reported that circumcision rites were practised in tropical zones of Africa, in the Philippines, by certain tribes in the Upper Amazon, and in Australia by women of the Arunta tribe. It also occurred among the early Romans and Arabs. As recent as the 1950s, clitoridectomy was practised in Western Europe and the United States to treat 'ailments' in women as diverse as hysteria, epilepsy, mental disorders, masturbation, nymphomania, melancholia and lesbianism. In other words, the practice of FGM/FGC has been followed by many different peoples and societies across the ages and the continents.
top
Who performs FGM/FGC?
FGM/FGC is usually carried out by elderly people in the community (usually, but not exclusively, women) who have been specially designated for this task, or by traditional birth attendants. These people receive a fee from the girls’ family members, in money or in kind. In some cases, medical personnel perform the operation as well, for a fee. Among certain populations, FGM/FGC may be carried out by traditional health practitioners, (male) barbers, members of secret societies, herbalists, and sometimes by a female relative.
top
What instruments are used to perform FGM/FGC?
FGM/FGC is carried out with special knives, scissors, scalpels, pieces of glass or razor blades. Anaesthetic and antiseptics are not generally used except when carried out by medical practitioners. In communities where infibulations is practised, the girls’ legs are often bound together to immobilize her for a period of 10 – 14 days, to allow formation of scar tissue.
top
What is done to stop the bleeding?
Paste mixtures of local herbs, porridge, ashes, mud, earth etc. are rubbed on the wound to stop the bleeding. In the case of type 3 (infibulation) the sides of the wound are stitched, or held together by thorns (e.g. from acacia trees).
top
At what age is FGM/FGC performed?
The age at which FGM/FGC is performed varies. In some areas it is carried out during infancy (as early as a couple of days after birth), in others during childhood, at the time of marriage, during a woman’s first pregnancy or after the birth of her first child. The most typical age is 7 – 10 years or just before puberty, although reports suggest that the age is dropping in some areas.
top
In which countries is FGM/FGC practiced?
The practice is common in parts of Africa, Asia and in some Arab Countries. It is practiced among communities in : Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Cote d’Ivoire , Democratic Republic of Congo, Djibouti, Egypt, Ethiopia, Eritrea, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, Somalia, Sudan, Tanzania, Togo, Uganda.
FGM/FGC is also practiced among certain ethnic groups in a number of Asian countries (India, Indonesia, Malaysia, Pakistan); among some groups in the Arabian Peninsula (in Oman, Saudi Arabia, United Arab Emirates, Yemen); and among certain immigrant communities in Europe, Australia, Canada and the United States.
top
Why is FGM/FGC performed?
Cultural practices such as FGM/FGC are rooted in a set of beliefs, values, cultural and social behaviour patterns that govern the lives of people in society. There are many reasons given for practicing FGM/FGC. These can be categorised under five headings:
Psychosexual reasons:
FGM/FGC is carried out as a means to control women’s sexuality (which is argued to be insatiable if parts of the genitalia, especially the clitoris, are not removed). It is thought to ensure virginity before and fidelity after marriage and/or to increase male sexual pleasure.
Sociological and cultural reasons:
FGM/FGC is seen as part of a girl’s initiation into womanhood and as an intrinsic part of a community’s cultural heritage/tradition. Various myths exist about female genitalia (e.g. that if uncut the clitoris will grow to the size of a penis; FGM/FGC would enhance fertility or promote child survival, etc) and these serve to perpetuate the practice.
Hygiene and aesthetic reasons:
In some communities, the external female genitalia are considered dirty and ugly and are removed ostensibly to promote hygiene and aesthetic appeal.
Religious reasons:
Although FGM/FGC is not sanctioned by either Islam nor by Christianity, supposed religious prescripts (e.g. the mention of ‘Sunna” in the Koran) are often used to justify the practice.
Socio-economic factors:
In many communities, FGM/FGC is a prerequisite for marriage. Where women are largely dependent on men, economic necessity can be a major determinant to undergo the procedure. FGM/FGC sometimes is a prerequisite for the right to inherit. FGM/FGC may also be a major income source for circumcisers.
top
How many women and girls are affected?
It is estimated that over 130 million girls and women have undergone some form of genital mutilation/cutting, and at least 2 million girls are at risk of undergoing the practice every year.
top
How does FGM/FGC affect women’s health?
The effects of FGM/FGC depend on the type performed, the expertise of the circumciser, the hygienic conditions under which it is conducted, the amount of resistance and general health condition of the girl/woman undergoing the procedure. Complications may occur in all types of FGM/FGC, but are most frequent with infibulation.
FGM/FGC has both immediate and long-term consequences to the health of women.
Immediate complications:
These include severe pain, shock, haemorrhage, tetanus or infection, urine retention, ulceration of the genital region and injury to adjacent tissue, wound infection, urinary infection, fever and septicaemia. Haemorrhage and infection can be of such magnitude as to cause death.
Long term consequences:
These include anemia, the formation of cysts and abscesses, keloid scar formation, damage to the urethra resulting in urinary incontinence, dyspareunia (painful sexual intercourse) and sexual dysfunction, hypersensitivity of the genital area. Infibulation can cause severe scar formation, difficulty in urinating, menstrual disorders, recurrent bladder and urinary tract infection, fistulae, prolonged and obstructed labour (sometimes resulting in fetal death and vesico-vaginal fistulae and/or vesico-rectal fistulae), and infertility (as a consequence of earlier infections). Cutting of the scar tissue is sometimes necessary to facilitate sexual intercourse and/or childbirth. Almost complete vaginal obstruction may occur, resulting in accumulation of menstrual flow in the vagina and uterus. During childbirth the risk of hemorrhage and infection is greatly increased.
top
Is there a link between FGM/FGC and the risk of HIV/AIDS infection?
Because the procedure is coupled with the loss of blood and use is often made of one instrument for a number of operations, the risk of HIV/AIDS transmission is increased by the practice. Also, due to damage to the female sexual organs, sexual intercourse can result in lacerations of tissues, which greatly increases risk of transmission. The same is true for childbirth and subsequent loss of blood.
top
What are the psychological effects of FGM/FGC?
Genital mutilation/cutting may leave a lasting mark on the life and mind of the woman who has undergone the procedure. The psychological stress may trigger behavioural disturbances in children, closely linked to the loss of trust and confidence in care-givers. In the longer term, women may suffer feelings of anxiety, depression, and frigidity. Sexual dysfunction may also be the cause for marital conflicts and eventual divorce.
top
Is FGM/FGC required by certain religions?
No. The practice of FGM/FGC is not prescribed by Islam, nor in the Bible. In fact, the practice predates Islam, and many religious leaders have denounced it. The practice cuts across religions and is practiced by Muslims, Christians, Ethiopian Jews, Copts, as well as by followers of certain traditional African religions. FGM/FGC is thus more a cultural than a religious practice.
top
Can FGM/FGC be condoned if it is carried out by medical professionals under hygienic circumstances?
No. FGM/FGC in any form should not be practised by health professionals in any setting – including hospitals or other health establishments. Unnecessary bodily mutilation cannot be condoned by health providers. FGM/FGC is harmful to the health of women and girls and violates their basic human rights and medicalization of the procedure does not eliminate this harm. On the contrary, it reinforces the continuation of the practice by seeming to legitimize it. Health practitioners should provide all necessary care and counseling for complications that may arise as a result of FGM/FGC.
top
Since FGM/FGC is part of a cultural tradition, can it still be condemned?
Yes. The function of culture and tradition is to provide a framework for human well-being; cultural arguments can never be used to condone violence against persons, male or female. Moreover, culture is not static, but constantly changing and adapting. Nevertheless, activities for the elimination of FGM/FGC should be developed and implemented in a way that is sensitive to the cultural and social background of the communities that practice it. Behaviour can change when people understand the hazards of certain practices and when they realize that it is possible to give up harmful practices without giving up meaningful aspects of their culture.
top
In which countries is FGM/FGC banned by law?
Africa:
Benin, Burkina Faso, Central African Republic, Chad, Cote d’Ivoire, Djibouti, Egypt (Ministerial decree), Ghana, Guinea, Kenya, Niger, Nigeria (multiple states), Senegal, Tanzania, Togo. In Sudan only the most severe form of FGM/FGC is forbidden by law.
Others:
Australia, Belgium, Canada, Denmark, New Zealand, Norway, Spain, Sweden, United Kingdom, United States (federal law, and specific state laws).
Penalties range from a minimum of six months to a maximum of life in prison. Several countries also include monetary fines in the penalty. As of June 2000, there have been prosecutions or arrests in Burkina Faso, Egypt, Ghana, France and Senegal. Belgium. Benin, Nigeria, and Uganda are proposing laws to ban the practice of FGM/FGC.
In September 2001, the European Parliament adopted a resolution on Female Genital Mutilation . The resolution calls on the member states of the European Union to pursue, protect and punish any resident who has committed the crime of FGM even if committed outside the frontier ("extraterritoriality") and calls on the Commission and the Council to take measures in regard to the issuing of residence permits and protection for the victims of the practice. The resolution also calls on the member states to recognise the right to asylum of women and girls at risk of being subject to FGM/FGC.
top
Which international and regional instruments can be used for FGM/FGC eradication?
Most governments in countries where FGM/FGC is practised have ratified international conventions and declarations that make provisions for the promotion and protection of the health of women and girls. These include, inter alia:
1948
The Universal Declaration of Human Rights proclaims the right of all human beings to live in conditions that enable them to enjoy good health and health care (art. 25).
1966
The International Covenants on Civil and Political Rights and on Economic, Social and Cultural Rights condemn discrimination on the grounds of sex, and recognize the universal right to the highest attainable standard of physical and mental health (art. 12).
1979
The Convention on the Elimination of All Forms of Discrimination against Women requires State Parties to : “take all appropriate measure to modify or abolish customs and practices which constitute discrimination against women “ (art. 2f). “modify social and cultural patterns of conduct of men and women, with a view to achieving the elimination of prejudices and customary and all other practices which are based on the idea of the inferiority or the superiority of either of the sexes” (art 5a).
General recommendation 24 (1999) to article 12 of the Convention (on women and health) emphasizes that certain cultural or traditional practices such as FGM/FGC carry a high risk of death and disability and recommends that State parties should ensure the enactment and effective enforcement of laws that prohibit FGM/FGC.
General recommendation 14 (1990) pertains particularly to FGM/FGC. It recommends that State parties take appropriate and effective measures to eradicate female circumcision; to collect and disseminate basic data on traditional practices; to support women’s organization at the national and local levels that work for the elimination of harmful practices; to encourage politicians, professionals, religious and community leaders to co-operate in influencing attitudes; to introduce appropriate educational and training programmes; to include appropriate strategies aimed at eradication of female circumcision into national health policies; to invite assistance, information and advice from the appropriate organization of the United Nations system; to include in their reports to the Committee under articles 10 and 12 of the Convention information about measures taken to eliminate female circumcision.
1989
The Convention on the Rights of the Child protects against all forms of mental and physical violence and maltreatment (art 19.1); to freedom from torture or cruel, inhuman or degrading treatment (art 37a), and requires States to take all effective and appropriate measures to abolish traditional practices prejudicial to the health of children (art 24.3)
1993
The Vienna Declaration and the Programme of Action of the World Conference on Human Rights expanded the international human rights agenda to include gender-based violence including FGM/FGC.
1994
The Programme of Action of the International Conference on Population and Development.
1995
The Platform for Action of the Fourth World Conference on Women includes a section on the girl child and urges governments, international organization and non-governmental groups to develop policies and programmes to eliminate all forms of discrimination against the girl child, including female genital cutting.
1997
The African Charter on Human and Peoples’ Rights, article 4 on integrity of the person, article 5 on human dignity and protection against degradation, article 16 on the right to health, article 18 (3) on protection of the rights of women and children.
The Addis Ababa Declaration. At the Council of Ministers during its sixty-eighth Session in July 1998, the Organization of African Unity (OAU) adopted the Addis Ababa Declaration on violence against Women. This Declaration was later endorsed by the Assembly of heads of State and Governments. The Declaration serves as an important step towards the formulation of an African charter on violence against women, providing the framework for national laws against FGM/FGC.
1998
The Banjul Declaration. The Inter-African committee on Traditional Practices Affecting the Health of Women and Children in collaboration with the Gambian committee on Traditional Practices (GAMCOTRAP) organized a symposium for religious leaders and medical personnel in Banjul, Gambia, from 20 to 24 July 1998. Participants agreed that FGM/FGC is not prescribed by any religion and unequivocally condemned the use of religion to justify the practice, emphasizing the importance of information campaigns to put and end to them. At the close of the symposium they issued a communique, a declaration and recommendations condemning and demanding eradication of FGM/FGC and other harmful traditional practices.
1999
The United Nations Social, Humanitarian and Cultural Committee (Third Committee of the General Assembly) approved a resolution that calls upon States to implement national legislation and policies that prohibit traditional or customary practices affecting the health of women and girls, including FGM/FGC. It also calls upon States to prosecute perpetrators of practices that negatively affect the health of women and girls, and to intensify efforts to raise awareness and mobilize international and national opinion on the harmful effects of such practices.
The Ouagadougou Declaration. A workshop on concerted action against the practice of FGM/FGC in the West African Economic and Monetary Union (UEMOA) was organized in Ouagadougou from 4 to 6 May 1999. Participants made three recommendations : a) the preparation of an African charter on FGM/FGC; b) the adoption of specific legislation against FGM/FGC in all UEMOA States and ratification by these of regional and international instruments relating to the protection of women and girls; and c) the establishment of sub-regional networks of traditional and religious leaders and modern and traditional communicators to support the national committees in their campaign against FGM/FGC. A declaration known as the Declaration of Ouagadougou was adopted at the end of the workshop.
Key Actions for the Further Implementation of the Programme of Action of the International Conference on Population and Development. It calls for governments to promote human rights of women and girls and freedom from coercion, discrimination, violence, including harmful practice, and sexual exploitation and to review national legislation and amend those that discriminate against women and girls. It also calls for governments to ensure supervision of health providers to make sure that they are knowledgeable and trained to serve clients who have been subjected to harmful practice.
2000
Further Actions and Initiatives to Implement the Beijing Declaration and Platform for Action. While it recognses the progress made in the national legislation process to ban the practice of FGM/FGC, it points out that discriminatory attitudes and norms persist that makes girls and women more vulnerable to gender-based violence including FGM/FGC. It calls for national governments’ actions to combat and eliminate violence against women that are incompatible with the dignity and worth of the person.
top
What terms do people who practice FGM/FGC use to describe the procedure?
Since FGM/FGC is practiced in different countries and cuts across ethnic groups, there are many different names used to describe different forms of FGM/FGC. For instance:
Sunna: Sunna means ‘precept’ or ‘tradition’ in Arabic and it refers to a range of practices that follow the teachings of Islam. It is used in various communities to refer to different types of FGM/FGC, varying from incisions in the clitoris to intermediate forms. References to the term ‘sunna’ in the Koran are often used to justify FGM/FGC as being a religious obligation.
top
What do women who underwent FGM/FGC have to say about it themselves?
In the following quotation Zainab (22) tells us that she was infibulated at the age of 8:
“My two sisters, myself and our mother went to visit our family back home. I assumed we were going for a holiday. A bit later they told us that we were going to be infibulated. The day before our operation was due to take place, another girl was infibulated and she died because of the operation. We were so scared and didn’t want to suffer the same fate. But our parents told us it was an obligation, so we went. We fought back; we really thought we were going to die because of the pain. You have one woman holding your mouth so you won’t scream, two holding your chest and the other two holding your legs. After we were infibulated, we had rope tied across our legs so it was like we had to learn to walk again. We had to try to go to the toilet, if you couldn’t pass water in the next 10 days something was wrong. We were lucky, I suppose, we gradually recovered and didn’t die like the other girl. But the memory and the pain never really goes”. (WHO)
Do you want to know more?
Some useful links to other sites on FGM/FGC: Rainbo, at www.rainbo.org, PATH, at www.path.org, WHO, at www.who.org
top
What does the ICPD Programme of Action say about FGM/FGC?
The Programme of Action of the International Conference on Population and Development recognizes that violence against women is a widespread phenomenon. It states that : “In a number of countries, harmful practices meant to control women’s sexuality have led to great suffering. Among them is the practice of female genital cutting, which is a violation of basic rights and a major lifelong risk to women’s health (para 7.35).
The Programme of Action urges “Governments and communities (to)… urgently take steps to stop the practice of female genital cutting and protect women and girls from all such similar unnecessary and dangerous practices. Steps to eliminate the practice should include strong community outreach programmes involving village and religious leaders, education and counseling about its impact on girls’ and women’s health, and appropriate treatment and rehabilitation for girls and women who have suffered cutting. Services should include counseling for women and men to discourage the practice.” (para 7.40)
In Chapter 4 (Gender Equality, Equity and Empowerment of Women) the following paragraphs pertain to FGM/FGC:
Para 4.4: “Countries should act to empower women and should take steps to eliminate inequalities between men and women as soon as possibly by :
c) Eliminating all practices that discriminate against women; assisting women to establish and realize their rights, including those that relate to reproductive and sexual health”.
Para 4.9: “Countries should take full measure to eliminate all forms of exploitation, abuse, harassment and violence against women, adolescents and children”.
top
What was said about FGC/FGC during the ICPD+5 review?
The Report of the Ad Hoc Committee of the Whole of the Twenty-first Special Session of the General Assembly, indicates key actions for the further implementation of the Programme of Action of the International Conference on Population and Development. It states that :
Para 42: “Governments should promote and protect the human rights of the girl child and young women, which include economic and social rights as well as freedom from coercion, discrimination and violence, including harmful practices and sexual exploitation.”
Para 43: “Governments and civil society should take actions to eliminate attitudes and practices that discriminate against and subordinate girls and women and that reinforce gender inequality.”
Para 48: “Governments should give priority to developing programmes and policies that foster norms and attitudes of zero tolerance for harmful and discriminatory attitudes, including son preference, which can result in harmful and unethical practices such as prenatal sex selection, discrimination and violence against the girl child and all forms of violence against women, including female genital mutilation, rape, incest, trafficking, sexual violence and exploitation.”
Para 52 f: “Governments, in collaboration with civil society, including non-governmental organizations, donors and the United Nations system, should : Ensure that sexual and reproductive health programmes, free of any coercion, provide pre-service and in-service training and supervision for al levels of health-care providers to ensure that they maintain high technical standards, including for hygiene; respect the human rights of the people they serve; are knowledgeable and trained to serve clients who have been subjected to harmful practices, such as female genital mutilation and sexual violence…”
Para 52 g: “Promote men’s understanding of their roles and responsibilities with regard to respecting the human rights of women; …… and promoting the elimination of harmful practices, such as female genital mutilation, and sexual and other gender-based violence, ensuring that girls and women are free from coercion and violence.”
top
What is UNFPA’s approach to FGM/FGC?
UNFPA addresses the practice of FGM/FGC not only because of its harmful impact on the reproductive and sexual health of women, but also because it is a violation of women’s fundamental human rights. The basis for a rights approach is the affirmation that human well-being and health is influenced by the way a person is valued, respected and given the choice to decide on the direction of her/his life without discrimination, coercion or neglect of attention. UNFPA addresses FGM/FGC in a holistic manner, within its cultural and religious context; however cultural arguments can not be used to condone harmful practices such as FGM/FGC.
top
Sources for FAQs on Female Genital Mutilation/Cutting
“Female Genital Mutilation. A Joint WHO/UNICEF/UNFPA Statement.” 1997
“Female Genital Mutilation: The Practice.” WHO Information Package. 1994
“Visions and Discussions on Genital Mutilation of Girls. An International Survey.” Jacqueline Smith, 1995.
“Caring for women with circumcision. A technical manual for healthcare providers.” Nahid Toubia, Rainbo, 1999
“Socio-cultural aspects of female genital cutting.” M. de Bruyn, KIT, 1998.
“Medical aspects of female genital mutilation.” E. Leye, K. Roelens, M. Temmerman. International Center for Reproductive Health, University of Gent. 1998 CRLP Factsheet on FGC
“s Lands wijs, ‘s lands eer? Vrouwenbesnijdenis en Somalische vrouwen in Nederland”. K. Bartels and I. Haaijer, 1992
“FGC management during pregnancy, childbirth and post-partum period.”. Background paper for WHO Consultation, 15-17 October 1997, Geveva. Prof. H. Rushwan.
“Learning about social change. A research and evaluation guidebook using female circumcision as a case study”. S. Izett, N. Toubia. Rainbo 1999
“Towards the Eradication of Female Genital Mutilation in Egypt”. M. Hekmati, 1999
ECOSOC document E/CN.4/Sub.2/1999/14 : “Third report on the situation regarding the elimination of traditional practices affecting the health of women and the girl child”, by Ms. Halima Embarek Warzazi, pursuant to sub-commission resolution 1998/16
General Assembly document A/54/34 : “Traditional or customary practices affecting the health of women”. Report of the Secretary-General
General Assembly document A/C.3/54/C.13 : “Traditional or customary practices affecting the health of women and girls”.
top
| Contact Us | Help/FAQs | Site Index | Other UN Sites | Terms & Conditions | Fraud - Hotline |
FGM: types. Complications. Risks.
Female Genital Mutilation: Complications and Risk
of HIV Transmission.
MARGARET BRADY, M.S.N., F.N.P.-C.
ABSTRACT
There are over 100 million girls and women who have undergone female genital mutilation (FGM). The World Health Organization (WHO) estimates that another 2 million are subject to it every year. FGM is practiced in many countries, especially Africa and parts of the Middle East. Various degrees of FGM are prevalent, the most mutilating one being infibulation (pharaonic). With infibulation there are numerous life-long health problems such as hemorrhage, infection, dyspareunia, genital ulcers, and gynecological and obstetrical complications. It has been postulated that FGM may also play a significant role in facilitating the transmission of HIV infection through numerous mechanisms. In this article several of the most common complications are discussed and helpful suggestions for management during pregnancy and delivery are explored. Included are the legal and ethical ramifications.
INTRODUCTION
FEMALE GENITAL MUTILATION (FGM), which is inaccurately referred to as female circumcision by some people, has been practiced for centuries. Egyptian mummies were found to have been circumcised as far back as 200 B. C. In the 19th Century it was practiced in Europe and North America as a remedy for ailments like epilepsy, hysteria, and masturbation.1 The practice of FGM is most prevalent in the African countries such as Nigeria, Ethiopia, Sudan, Egypt, and some area of the Middle East. It is not restricted to any ethnic, religious or socioeconomic class. There are many reasons for perpetuation of this practice, the most common are cultural and religious beliefs. Although often associated with Islam, it is also practiced by other religious groups, including Christians. There is no mention of it in the Koran. An overwhelming factor for its justification is the cultural influence and traditions, social acceptance within the community, and ensuring chastity and fidelity by attenuating sexual desire.2,3 A research study done in Nigeria on the Igbos tribe found that women believe that FGM makes them more feminine and thus more attractive to men.4 A recent social study carried out established that FGM raises the social status for the family and generates income when the daughter gets married and the dowry is paid.5
CLINICAL TOPOGRAPHY
The World Health Organization (WHO), in an effort to standardize the terminology has divided FGM into four main groups. Dr. Naid Toubia, who has researched and written extensively on this topic, has identified two types. He combines type I and II and divides infibulation into type III and IV.6 This is not the case with WHO. For the purposes of this article, the WHO clinical classifications will be followed.
Type I—Clitoridectomy is the removal of prepuce and all or part of the clitoris. Also called Sunna Circumcision.6-8 This is the least mutilating one.
Type II—The clitoris and part of the labia are excised and then sewn together by sutures, thorns, or tying the girl's legs together until the edges have united.7
Type III—Infibulation (pharaonic) is the most extreme. Here the clitoris, labia minora are excised and incisions made in the labia majora to create raw surfaces that are then either stitched together or kept in close contact until they seal and form a cover for the urethral meatus. A very small orifice is left for the passage of urine and menstrual flow. Because this type is the most mutilating, the medical, obstetrical, and psychological complications are more profound. In many regions it is the most common procedure performed (e.g., in Djibouti and Somalia 98% of FGM are infibulations).6,7,9 (See Fig. 1)
WHO has indentified a new category type IV, which encompasses other types of operations such as gihiri cut, piercing, cauterization, and insertion of corrosive substances into the vagina. Of course, one must remember that FGM is carried out mainly in villages by lay people, with little knowledge of anatomy, so there often occurs a combination of all of these types. FGM is performed any time from birth to just before marriage, but most commonly done between the ages of 4 to 10 years.10
COMMON COMPLICATIONS
Complications following FGM, especially if the girl is infibulated, are common and many are well documented. These may be immediate or late. The major immediate complications are, of course, hemorrhage from the dorsal artery, shock and then infection, urinary retention and tetanus, which can lead to mortality.10-12
Some late and long-term complications seen are urinary incontinence, cysts, urogenital tract infections, severe dyspareunia, pelvic inflammatory disease, infertility, and obstetrical problems such as delayed or obstructed second stage labor, trauma, and hemorrhage. Hemorrhage was also seen as a late complication especially in the newly married girl who was tightly infibulated and was subjected to forcible sex by the husband or who the husband defibulated using various instruments such as scissors, blades or knives.1,6,12,13.
In the research done by Dirie and Lindmark in Somalia on 290 women (mean age 22 years, range 18 to 54), 88% of research subjects had excision and infibulation, the remainder fell into the less mutilating categories. Sixty-nine percent had this procedure performed at home and 52% of these were performed by an untrained person. The immediate main complication reported by 112 women in the study was hemorrhage, infection, urinary retention, and septicemia (see Table 1). Five women reported severe schock and two of them required blood transfusions. Those women with urinary retention were treated by splitting the infibulation scar and were reinfibulated a few weeks later. The late complication of which 108 women complained, were as follows: 36 with clitoral cysts, 29 requiring excision; 57 with pain on micturition; and 15 subjects had poor urinary flow (see Table 2).
Hemorrhage is an immediate as well as a late complication. For hemostasis the girl's legs are tied together and sometimes a poultice of crushed medicinal herbs is applied.4
The urinary retention reported by the women in the Dirie/Lindmark study occurred within the first 3 days after the operation and the reason given by the authors was that the girls tried to avoid passing urine because of the pain that urine causes when it irritates the raw surfaces. The retention was also due to skin flaps, blood clots or, in several cases the urinary meatus was sutured while closing the vulva.
Recurrent urinary tract infections and urinary problems were numerous, and according to Dirie/Lindmark, these were caused because the meatus was covered by the infibulation, causing vaginal dischange to accumulate and favor the growth of bacteria. The women reported that they were given antibiotics by their doctor and this helped.1 DeSilva14 reported that urinary tract infection with Escherichia coli was common in these women.
The most common late complication of FGM that was reported by Dirie and several other authors was vulvar swelling, which was due to epidermal cyst formation that develops along the scar tissue and in the excised clitoral region. Hanly13 discusses 10 patients that attended the hospital in Tabuk, Saudia Arabia. All patients were immigrants into the Kingdom from Africa. Six patients presented with a large painless mass in the infibulation scar. Two complained of pain, one gave a history of a white continuous secretion for the scar site, and one complained of severe dyspareunia and had a cyst measuning 5.5 X 5 X % cm. The pathological finding in eight patients was of an implantation dermoid, in the other two patients the cyst had ruptured.
Mayad11 discusses the fibrous connective tissue tumors called fibromata. These form in the same areas as the dermoid cysts and also can grow to be large and pedunculated.
SEXUALLY TRANSMITTED DISEASE,
PELVIC INFLAMMATORY DISEASE,
AND INFERTILITY
Pelvic inflammatory disease (PID), a common complication of sexually transmitted disease (STD) is accompanied by abdominal pain, infertility, and ectopic pregnancy. Research indicates that PID is a major problem worldwide and in some African countries, 22 to 44% of women admitted to the hospital for gynecological problems had PID. In women 20-29 years old, 7 to 25% of them were childless.15 The most prevalent organisms were Neisseria gonnorrhoeae and Chlamydia trachomatis. However, it is now believed that FGM plays a significant role in the development of PID. For the woman who has been infibulated there are added risks of infection and resulting infertility. It has been reported by Sami and El Dareer3 that chronic pelvic disease was three times more prevalent in the infibulated women. Chronic retention of unire, menstrual flow, and repeated urinary tract infections with E. coli are the consequences of poor drainage, which results from a space fromed behind the vulva skin. This then becomes an excellent reservoir for the growth of pathogenic organisms such as the E. coli.3,14,16
Shandall17 and DeSilva14 reported a high incidence of candiasis, which was more frequent with infibulation, and urine cultures showed the presence of mixed organisms, specifically E. coli. Shandall has suggested three main causes of PID in the infibulated woman, namely: (1) infection at the time of infibulation, (2) interference with drainage and (3) infection from spliting the infibulation and resulting resuture after labor. The infections then spread to the inner reproductive organs causing infertility.14,16,17
Rushwan states that FGM should be recognized as an important etiological factor for PID.18 Another reason for infertility is acquired gynetresia which according to Ozumba, is directly related to infibulation. In a study done by Ozumba in Eastern Nigeria on 78 women (see Tables 3 and 4), 59 patients (76%) had acquired gynetresia caused by infibulation. Sexual intercourse is generally difficult and the process of deinfibulation painful and can take 2-12 weeks to complete or even up to 2 years during which time the women seeks medical help for infertility.19
It is estimated that 2-25% of the cases of infertility in the Sudan are due to infibulation, either as a result of chronic pelvic infection or because of difficulty in having sexual intercourse and lack of penetration. In this society the psychological and social impact of being sterile must be profound because a woman's worth is frequently measured by her fertility, and being sterile can be cause for a divorce.
POSSIBLE HIV TRANSMISSION
It has been postulated that FGM may play a role in the transmission of HIV. One recent article which, was presented at the International Conference on AIDS 1998, was a study performed on 7350 young girls less than 16 years old in Dar es Salaam. In addition to other aspects of the research, it was revealed that 97% of the time, the same equipment could be used on 15-20 girls. The conclusion of the study was that the use of the same equipment facilitated HIV/AIDS/STD transmission.20
At the same conference, a research study performed in Nairobi indicated that FGM predisposes women to HIV infection in many ways (e.g., increased need for blood transfusions due to hemorrhage either when the procedure is performed, at childbirth, or a result of vaginal tearing during defibulation and intercourse, and the use of the same instruments for other initiates). Because FGM raises the social status of the parents, the dowry demands can be high and therefore the young girls can be married off to older men who are already infected.5 Contact with blood during intercourse is believed to be responsible for the transmission on HIV infection among homosexuals.21
Women who have had FGM done have a small opening, just large enough for the passage of urine and blood. Penetration or intercourse is difficult, often resulting in tissue damage, lesions, and postcoital bleeding. These tears would tend to make the squamous vaginal epithelium similar in permeability to the columnar mucosa of the rectum, thus facilitaing the possible transmission of HIV.22 The vaginal introitus is narrowed to increase the man's sexual enjoyment and ensure fidelity and virginity. However, because of the this many women experience severe dyspareunia.9,16 Other common reasons for the dyspareunia are epidermal or dermoid cysts, which form along the incisional site. These can be a small as a pea or as large as a football.13 These often become infected, painful, and a common reason for the woman seeking medical help. Dyspareunia can also be a result of neuromata that are formed when the dorsal nerve ending is trapped in scar tissue, resulting in immense pain and severe dyspareunia.23-25.
Unlike the rest of the world, sub-Saharan Africa has been more severely affected by HIV/AIDS. The sheer number of Africans infected is overwhelming. What is also of interest and concern is the number of women who are infected. The latest statistical data coming from WHO indicates that in Africa the ratio of male to female is 1:1, while in Europe and North America it is 4:1 (see Table 5). In Zimbabwe at 23 surveillance sites where the pregnant women were all tested anonymously for HIV, some 20-50% of them were found to be infected. At least one third of these women are likely to pass the infection on to their baby.26
Linke points to the common factor of contact with blood during intercourse for transmission of HIV in homosexuals in the United States and heterosexuals in Africa.21 For many of the women with FGM who have been infibulated (pharaonic), vagina intercourse is difficult at best and is associated with repeated tissue damage and bleeding, subsequently anal intercourse is resorted to with heterosexual partners. Thus the proposition that HIV transmission is enhanced because of the widespread practice of FGM.21,25
It is difficult for researchers to obtain accurate statistical data on anal intercourse for a host of reasons. Because of their cultural background, African women feel uncomfortable and shy discussing their sexual habits, and this is certainly true in the presence of males other than their husbands. Societal disapproval of anal intercourse is especially strong in areas where the majority of the population is Catholic, and admitting such behaviors can involve ostracization from the community.21 Moore et al.,27 in a study done on 1480 students in Zaire, found that 19% stated that they practiced anal intercourse. Because the question of homosexuality and anal sex is considered taboo, many Africans, male and female, are unwilling to discuss or admit to these practices, so these are believed to be grossly underreported. There is a large body of convincing evidence that genital ulceration and other STDs increase susceptibility to HIV infection.28 In reseach done by Allen et al.29 on HIV infection in urban Rwanda, the association between dyspareunia and nonmenstrual bleeding are often seen as signs and symptoms of undiagnosed venereal disease.29 In fact, in almost all of the research, genital lesions and ulcerations are discussed in the context of STD. The European study did report that in women with a history of candidiasis, the rate of HIV infection was significantly higher.30 As stated earlier and by many authors, included in the complications of HIV infection was significantly higher.30 As stated earlier and by many authors, included in the complications of FGM are severe dyspareunia, postcoital bleeding, ulceration and a high incidence of candidiasis.3,6,10,23,21,29 There is no conclusive evidence on the linkage of FGM to HIV transmission. However, Post31 describes an incident from a letter sent by the Minority Rights Group to Ammnesty International as follows: "While in Malawi a couple of months ago, I came across the story of a 14 year-old girl of Yao tribe that inhabits land in the Southern end of the country. She was diagnosed as HIV-positive although she was a virgin. Blame was laid on the fact that during tribal circumcision, the same razor would be used on any number of children at the same time."31 Perhaps future research on HIV transmission should include, as a variable, women who have had FGM performed because they also have genital ulcers and abrasions. If there were conclusive evidence linking FGM with the transmission of HIV, this may then become the best weapon in the arsenal for eradication of this practice.
OBSTETRICAL COMPLICATIONS
There are many obstetrical complications associated with infibulation, for the mother and fetus/baby. However, Mawad and other authors11 stress that with careful planning, good antenatal, intrapartum and postpartum care, most of these can be avoided. Some of the main complications are delayed second-stage labor, perineal tearing, vesicovaginal fistula, and low birth weight babies. It has been reported that some pregnant women reduce their dietary intake to avoid giving birth to large babies.32 The obstetrical management for those patients is important and often difficult for those that have not had this type of exposure.
The Norwich Park Hospital in the United Kingdom has established an "African Well Woman Clinic" with a specially trained staff and protocols in place for the management of the FGM women. The necessity for this arose because of the high influx of immigrants from the Sudan and Somalia. These areas in Africa are where infibulation is practiced on at least 95% of the women. On staff there is a female Somali translator and a Sudanese psychologist. Since the clinic's inception the number of persons visiting the clinic has risen from under 1% to almost 6%. In the research done by McCaffery on 50 of the patients that attended the clinic, 13 were nonpregnant, 14 were primigravida, and 23 multigravida. The main reason for the nonpregnant women's attendance was to request defibulation. At first visit the average gestational age was 15-20 weeks. Of the 14 primigravida patients, 7 had an adequate introitus to facilitate first- and second-stage labor. One patient had a deinfibulation done earlier, two requested antenatal deinfibulation and three preferred the procedure to be done at the time of delivery (one patient did not return to the clinic). Thirteen (93%) primigravida patients had vaginal deliveries, and all of these had either episiootomies or perineal lacerations. Fourteen (61%) multiparous had vaginal deliveries. Six (25.1%) had caesarean sections, and with three (13%) instrumentation was used. Included in this research is an excellent in-depth discussion of the problems encountered and the obstetrical management Two cases are discussed in detail. The first was a 26-year-old Sudanese (primigravida) presented at 26 weeks gestation with severe vulval itching. The introital opening measured less than 1 cm, so a speculum exam was not possible. A swab was passed and cultured Candida albicans. However, the insertion of the applicator for clotrimazole cream was not possible. Because of the severity of her symptoms, the woman underwent defibulation at 28 weeks' gestation and subsequently had a normal vaginal delivery.
For the infibulated mother in labor with a narrow introitus, the inability to do a vaginal exam to monitor progress, apply fetal scalp electrodes, or blood sampling are for the obstetrician mid-wife serous reasons for concern. The second case discussed was that of a 20-year-old Somali primigravida admitted with contractions at full term. The introitus barely admitted one finger and cardiotocography of the fetal heart showed 60 bpm without a contraction. An epidural anesthesia was administered to facilitate vaginal exam, and at this time the cervix was 2 cm dilated. Artificial rupture of the membrane was performed and revealed thick black meconium. The decision was made to perform a cesarean section. However a catherization could not be done, so deinfibulation was carried out to facilitate this.33 The author while in Saudia Arabia in 1980, found that a urethral catherization on the infibulated woman was quite difficult and unsuccessful at times due to extensive scar tissue, bands, and anatomical distortion. Valuable time can be lost in an emergency. The staff at the African Well Woman Clinic have developed a high level of expertise in caring for the infibulated woman, and from research it is evident that they have incorporated all aspects of well-being including psychological and cultural. The staff strongly recommends antenatal defibulation or elective reversal either before pregnancy, at 20 weeks gestation or if seen later in pregnancy than at 38 weeks. It takes about 1 week for the reversal to heal. This procedure should be performed under spinal anesthesia because the sensation of touch triggers flashbacks of the infibulation in childhood. In the nonpregnant women, general anesthesia is recommended.
LEGAL RAMIFICATIONS
Many countries such as Canada, England, Sweden, Australia, and others have enacted statutes prohibiting FGM and reinfibulation after delivery. In the United States a law was passed in 1997 which criminalizes FGM performed on a person who has not reached the age of 18 years but it does not address women older than 18 or reinfibulation after delivery. Infibulation was made illegal in Sudan in 1946 and still today nearly 90% of the women in Sudan have been subjected to FGM.24 Because FGM is now illegal, many young girls are taken out of the country to have it performed. The Center for Disease Control and Prevention estimates that there are over 150,000 females at risk in the United States for undergoing FGM.35 Clearly it will take more than legislation to eradicate this practice that can no longer be seen as a religious or traditional custom. One cannot mount an ethical defense for a practice that results in such a negative impact on a woman's health. This is not only a problem for countries where it is performed, but also for the Western Countries.
Health-care providers have an important role to fulfill in the eradication of this practice. We should act as advocates and increase professional and public awareness about such a practice, explaining the dangers and life-long disabilities it imposes. Perhaps the well-known crusader for eradication of FGM, who herself had this done, Merserak (Mimi) Ramsey, spoke for all women when she said, "This is a pain that doesn't go away. It is a lifetime wound,"36
REFERENCES
Dirie MA, Lindmark G. The risk of medical complications after female circumcision. East Afr Med J. 1992;62:479-482.
Council Report. Female genital mutilation. JAMA 1995;274(21):1714-1716.
El Dareer A. Complications of female circumcision in the Sudan. Trop Doct 1983;13:131-133 [PubMed]
Egwatu V, Agusa N. Complications of female circumcision in Nigerian Igbos. Br J Obstet Gynecol 1981;88:1090-1093. [Abstract]
Oyugi C. Social cultural factors that promote female circumcision and how this predisposes women to HIV infection. (Abst. 60067) Inter Conf on AIDS 1998;12:1011. [NLM Gateway]
Toubia N. a href="http://www.nejm.org/content/1994/0331/0011/0712.asp" target="_blank">Female circumcision as a public health measure. N Engl J Med 1994;331:712-716
Karungary K. Female genital mutilation: A reproductive health concern. Population Rep 1995:23:4. [PubMed]
Odoi A, Brody SP, Elkins RE. Female genital mutilation in rural Ghana, West Africa. Intern J Gynecaecol Obstet 1997;56:179-180.
Female genital mutilation in Nigeria. Lagos, Nigeria, Inter-African Committee on Practices Affecting the Health of Women and Children, Nigeria, 1997, 3. Monograph Series on Harmful and Beneficial Practices in Nigeria, no. 1.
Fox EF, de Ruiter A, Bingham S. Female genital mutilation. Intern J STD AIDS 1997;8:599-601. [PubMed]
Mawad NM, Hassanein OM. Female circumcision: Three years' experience of common complications in patients treated in Khartoum teaching hospitals. J Obstet Gynaecol 1994;14:40-43.
Black JA, DeBelle GD. Female genital mutilation in Britain. BMJ 1995;310:1590-1592.
Hanly GM, Objeda VJ. Epidermal inclusion cysts of the clitoris as a complication of female circumcision and pharonic infibulation. Cent Afr J Med 1995;41:22-24. [PubMed]
DeSilva S. Obstetric sequelae of female circumcision. Eur J Obstet Gynaecol Reprod Biol 1989;32:233-240. [PubMed]
Rowe PJ. Worldwide patterns of infertility: Is Africa different? Lancet 1985;2:596-598. [PubMed]
Sami J. Female circumcision with special reference to the Sudan. Ann Trop Paediatr 1986;6:99-115.
Shandall A. Circumcision and infibulation of female. Sudan Med J 1976;5:178-212.
Rushwan H. Etiologic factor in pelvic inflammatory disease in Sudanese women. Am J Obstet Gynecol 1980;138:877-879.
Ozumba BC. Acquired gynetresia in Eastern Nigeria. Int J Gynaecol Obstet 1992;37:105-109. [PubMed]
Mutenbei IB, Mwesiga MK. The impact of obsolete traditions on HIV/AIDS rapid transmission in Africa: The case of compulsory circumcision on young girls in Tanzania. (Abst 23473). Int Conf on AIDS 1998;12:436. [NLM Gateway]
Linke U. AIDS in Africa. Science 1986;231:203.
Hrdy DB. Cultural practices contributing to the transmission of human immunodeficiency virus in Africa. Rev Infect Dis 1987;9(6):1109-1117.
Kun KE. Female genital mutilation: the potential for increased risk of HIV infection. Int J Gynecol Obstetr 1997;15:153-155.
Toubia N. Female genital mutilation and the responsibility of reproductive health professionals. Intern J Gynecol Obstet 1994;46:127-135.
Arbesman M, Kahler L, Buck G. Assessment of the impact of female circumcision on the gynecological genitourinary and obstetrical health problems of women from Somalia: Literature Review and Case Studies. Women Health 1993,20:27-42. [Abstract]
WHO Statistical Information System. AIDS/HIV Statistics, http://www.who.int/whois/index.html.
Moore M, Bomboko B, Bertrand W, Moumoulini A, Kashala TD. Distribution and determinants for risk behaviour of HIV infection among young adults in Zaire: A "KAP" study. (Abst. Th C 105) Int Conf AIDS 1990;6:160.
Piot P, Laga M. Genital ulcers, other sexually transmitted diseases, and the sexual transmission of HIV. BMJ 1989;298:623-624. [PubMed]
Allen S, Lindan C, et al. Human immunodeficiency virus infection in urban Rwanda. JAMA 1991;266:1657-1663. [Abstract]
European Study Groups on Heterosexual transmission of HIV. Comparison of female to male and male to female transmission of HIV in 563 stable couples. BMJ 1992;304:809-812.
Post MT. Female genital mutilation and the risk of HIV. Washington, DC: Academy for Educational Development, support for Analysis and Research in Africa, 1995;1-10.
Calder B, Brown Y, Rae D. Female circumcision/genital mutilation: Culturally sensitive care. Health Care Women Int 1993;331:712-716. [PubMed]
McCaffery M. Management of female genital mutilation: The Northwick Park Hospital experience. Br J Obstet Gynaecol 1995;102:787-790. [PubMed]
Paul B. Maternal mortality in Africa. Soc Sci Med 1993;37:745-752. [PubMed]
Golara M, Morris N, Gordon H. Prevention of genital tract trauma during labour and delivery in an African population following female genital mutilation. J Obstet Gynaecol 1998;18:49-51.
AJN Newsline. A nurse wins her battle to ban FGM. AJN 1996;69:71.
Address reprint requests to:
Margaret Brady
Hostos Community College
500 Grand Concourse
Bronx, NY 10451
E-mail: BradyFNP@aol.com
Comments:
Comment in: AIDS Patient Care STDS 1999 Dec;13(12):683-8
--------------------------------------------------------------------------------
Citation:
Brady M. Female genital mutilation: complications and risk of HIV transmission. Aids Patient Care STDS 1999;13(12):709-16.
of HIV Transmission.
MARGARET BRADY, M.S.N., F.N.P.-C.
ABSTRACT
There are over 100 million girls and women who have undergone female genital mutilation (FGM). The World Health Organization (WHO) estimates that another 2 million are subject to it every year. FGM is practiced in many countries, especially Africa and parts of the Middle East. Various degrees of FGM are prevalent, the most mutilating one being infibulation (pharaonic). With infibulation there are numerous life-long health problems such as hemorrhage, infection, dyspareunia, genital ulcers, and gynecological and obstetrical complications. It has been postulated that FGM may also play a significant role in facilitating the transmission of HIV infection through numerous mechanisms. In this article several of the most common complications are discussed and helpful suggestions for management during pregnancy and delivery are explored. Included are the legal and ethical ramifications.
INTRODUCTION
FEMALE GENITAL MUTILATION (FGM), which is inaccurately referred to as female circumcision by some people, has been practiced for centuries. Egyptian mummies were found to have been circumcised as far back as 200 B. C. In the 19th Century it was practiced in Europe and North America as a remedy for ailments like epilepsy, hysteria, and masturbation.1 The practice of FGM is most prevalent in the African countries such as Nigeria, Ethiopia, Sudan, Egypt, and some area of the Middle East. It is not restricted to any ethnic, religious or socioeconomic class. There are many reasons for perpetuation of this practice, the most common are cultural and religious beliefs. Although often associated with Islam, it is also practiced by other religious groups, including Christians. There is no mention of it in the Koran. An overwhelming factor for its justification is the cultural influence and traditions, social acceptance within the community, and ensuring chastity and fidelity by attenuating sexual desire.2,3 A research study done in Nigeria on the Igbos tribe found that women believe that FGM makes them more feminine and thus more attractive to men.4 A recent social study carried out established that FGM raises the social status for the family and generates income when the daughter gets married and the dowry is paid.5
CLINICAL TOPOGRAPHY
The World Health Organization (WHO), in an effort to standardize the terminology has divided FGM into four main groups. Dr. Naid Toubia, who has researched and written extensively on this topic, has identified two types. He combines type I and II and divides infibulation into type III and IV.6 This is not the case with WHO. For the purposes of this article, the WHO clinical classifications will be followed.
Type I—Clitoridectomy is the removal of prepuce and all or part of the clitoris. Also called Sunna Circumcision.6-8 This is the least mutilating one.
Type II—The clitoris and part of the labia are excised and then sewn together by sutures, thorns, or tying the girl's legs together until the edges have united.7
Type III—Infibulation (pharaonic) is the most extreme. Here the clitoris, labia minora are excised and incisions made in the labia majora to create raw surfaces that are then either stitched together or kept in close contact until they seal and form a cover for the urethral meatus. A very small orifice is left for the passage of urine and menstrual flow. Because this type is the most mutilating, the medical, obstetrical, and psychological complications are more profound. In many regions it is the most common procedure performed (e.g., in Djibouti and Somalia 98% of FGM are infibulations).6,7,9 (See Fig. 1)
WHO has indentified a new category type IV, which encompasses other types of operations such as gihiri cut, piercing, cauterization, and insertion of corrosive substances into the vagina. Of course, one must remember that FGM is carried out mainly in villages by lay people, with little knowledge of anatomy, so there often occurs a combination of all of these types. FGM is performed any time from birth to just before marriage, but most commonly done between the ages of 4 to 10 years.10
COMMON COMPLICATIONS
Complications following FGM, especially if the girl is infibulated, are common and many are well documented. These may be immediate or late. The major immediate complications are, of course, hemorrhage from the dorsal artery, shock and then infection, urinary retention and tetanus, which can lead to mortality.10-12
Some late and long-term complications seen are urinary incontinence, cysts, urogenital tract infections, severe dyspareunia, pelvic inflammatory disease, infertility, and obstetrical problems such as delayed or obstructed second stage labor, trauma, and hemorrhage. Hemorrhage was also seen as a late complication especially in the newly married girl who was tightly infibulated and was subjected to forcible sex by the husband or who the husband defibulated using various instruments such as scissors, blades or knives.1,6,12,13.
In the research done by Dirie and Lindmark in Somalia on 290 women (mean age 22 years, range 18 to 54), 88% of research subjects had excision and infibulation, the remainder fell into the less mutilating categories. Sixty-nine percent had this procedure performed at home and 52% of these were performed by an untrained person. The immediate main complication reported by 112 women in the study was hemorrhage, infection, urinary retention, and septicemia (see Table 1). Five women reported severe schock and two of them required blood transfusions. Those women with urinary retention were treated by splitting the infibulation scar and were reinfibulated a few weeks later. The late complication of which 108 women complained, were as follows: 36 with clitoral cysts, 29 requiring excision; 57 with pain on micturition; and 15 subjects had poor urinary flow (see Table 2).
Hemorrhage is an immediate as well as a late complication. For hemostasis the girl's legs are tied together and sometimes a poultice of crushed medicinal herbs is applied.4
The urinary retention reported by the women in the Dirie/Lindmark study occurred within the first 3 days after the operation and the reason given by the authors was that the girls tried to avoid passing urine because of the pain that urine causes when it irritates the raw surfaces. The retention was also due to skin flaps, blood clots or, in several cases the urinary meatus was sutured while closing the vulva.
Recurrent urinary tract infections and urinary problems were numerous, and according to Dirie/Lindmark, these were caused because the meatus was covered by the infibulation, causing vaginal dischange to accumulate and favor the growth of bacteria. The women reported that they were given antibiotics by their doctor and this helped.1 DeSilva14 reported that urinary tract infection with Escherichia coli was common in these women.
The most common late complication of FGM that was reported by Dirie and several other authors was vulvar swelling, which was due to epidermal cyst formation that develops along the scar tissue and in the excised clitoral region. Hanly13 discusses 10 patients that attended the hospital in Tabuk, Saudia Arabia. All patients were immigrants into the Kingdom from Africa. Six patients presented with a large painless mass in the infibulation scar. Two complained of pain, one gave a history of a white continuous secretion for the scar site, and one complained of severe dyspareunia and had a cyst measuning 5.5 X 5 X % cm. The pathological finding in eight patients was of an implantation dermoid, in the other two patients the cyst had ruptured.
Mayad11 discusses the fibrous connective tissue tumors called fibromata. These form in the same areas as the dermoid cysts and also can grow to be large and pedunculated.
SEXUALLY TRANSMITTED DISEASE,
PELVIC INFLAMMATORY DISEASE,
AND INFERTILITY
Pelvic inflammatory disease (PID), a common complication of sexually transmitted disease (STD) is accompanied by abdominal pain, infertility, and ectopic pregnancy. Research indicates that PID is a major problem worldwide and in some African countries, 22 to 44% of women admitted to the hospital for gynecological problems had PID. In women 20-29 years old, 7 to 25% of them were childless.15 The most prevalent organisms were Neisseria gonnorrhoeae and Chlamydia trachomatis. However, it is now believed that FGM plays a significant role in the development of PID. For the woman who has been infibulated there are added risks of infection and resulting infertility. It has been reported by Sami and El Dareer3 that chronic pelvic disease was three times more prevalent in the infibulated women. Chronic retention of unire, menstrual flow, and repeated urinary tract infections with E. coli are the consequences of poor drainage, which results from a space fromed behind the vulva skin. This then becomes an excellent reservoir for the growth of pathogenic organisms such as the E. coli.3,14,16
Shandall17 and DeSilva14 reported a high incidence of candiasis, which was more frequent with infibulation, and urine cultures showed the presence of mixed organisms, specifically E. coli. Shandall has suggested three main causes of PID in the infibulated woman, namely: (1) infection at the time of infibulation, (2) interference with drainage and (3) infection from spliting the infibulation and resulting resuture after labor. The infections then spread to the inner reproductive organs causing infertility.14,16,17
Rushwan states that FGM should be recognized as an important etiological factor for PID.18 Another reason for infertility is acquired gynetresia which according to Ozumba, is directly related to infibulation. In a study done by Ozumba in Eastern Nigeria on 78 women (see Tables 3 and 4), 59 patients (76%) had acquired gynetresia caused by infibulation. Sexual intercourse is generally difficult and the process of deinfibulation painful and can take 2-12 weeks to complete or even up to 2 years during which time the women seeks medical help for infertility.19
It is estimated that 2-25% of the cases of infertility in the Sudan are due to infibulation, either as a result of chronic pelvic infection or because of difficulty in having sexual intercourse and lack of penetration. In this society the psychological and social impact of being sterile must be profound because a woman's worth is frequently measured by her fertility, and being sterile can be cause for a divorce.
POSSIBLE HIV TRANSMISSION
It has been postulated that FGM may play a role in the transmission of HIV. One recent article which, was presented at the International Conference on AIDS 1998, was a study performed on 7350 young girls less than 16 years old in Dar es Salaam. In addition to other aspects of the research, it was revealed that 97% of the time, the same equipment could be used on 15-20 girls. The conclusion of the study was that the use of the same equipment facilitated HIV/AIDS/STD transmission.20
At the same conference, a research study performed in Nairobi indicated that FGM predisposes women to HIV infection in many ways (e.g., increased need for blood transfusions due to hemorrhage either when the procedure is performed, at childbirth, or a result of vaginal tearing during defibulation and intercourse, and the use of the same instruments for other initiates). Because FGM raises the social status of the parents, the dowry demands can be high and therefore the young girls can be married off to older men who are already infected.5 Contact with blood during intercourse is believed to be responsible for the transmission on HIV infection among homosexuals.21
Women who have had FGM done have a small opening, just large enough for the passage of urine and blood. Penetration or intercourse is difficult, often resulting in tissue damage, lesions, and postcoital bleeding. These tears would tend to make the squamous vaginal epithelium similar in permeability to the columnar mucosa of the rectum, thus facilitaing the possible transmission of HIV.22 The vaginal introitus is narrowed to increase the man's sexual enjoyment and ensure fidelity and virginity. However, because of the this many women experience severe dyspareunia.9,16 Other common reasons for the dyspareunia are epidermal or dermoid cysts, which form along the incisional site. These can be a small as a pea or as large as a football.13 These often become infected, painful, and a common reason for the woman seeking medical help. Dyspareunia can also be a result of neuromata that are formed when the dorsal nerve ending is trapped in scar tissue, resulting in immense pain and severe dyspareunia.23-25.
Unlike the rest of the world, sub-Saharan Africa has been more severely affected by HIV/AIDS. The sheer number of Africans infected is overwhelming. What is also of interest and concern is the number of women who are infected. The latest statistical data coming from WHO indicates that in Africa the ratio of male to female is 1:1, while in Europe and North America it is 4:1 (see Table 5). In Zimbabwe at 23 surveillance sites where the pregnant women were all tested anonymously for HIV, some 20-50% of them were found to be infected. At least one third of these women are likely to pass the infection on to their baby.26
Linke points to the common factor of contact with blood during intercourse for transmission of HIV in homosexuals in the United States and heterosexuals in Africa.21 For many of the women with FGM who have been infibulated (pharaonic), vagina intercourse is difficult at best and is associated with repeated tissue damage and bleeding, subsequently anal intercourse is resorted to with heterosexual partners. Thus the proposition that HIV transmission is enhanced because of the widespread practice of FGM.21,25
It is difficult for researchers to obtain accurate statistical data on anal intercourse for a host of reasons. Because of their cultural background, African women feel uncomfortable and shy discussing their sexual habits, and this is certainly true in the presence of males other than their husbands. Societal disapproval of anal intercourse is especially strong in areas where the majority of the population is Catholic, and admitting such behaviors can involve ostracization from the community.21 Moore et al.,27 in a study done on 1480 students in Zaire, found that 19% stated that they practiced anal intercourse. Because the question of homosexuality and anal sex is considered taboo, many Africans, male and female, are unwilling to discuss or admit to these practices, so these are believed to be grossly underreported. There is a large body of convincing evidence that genital ulceration and other STDs increase susceptibility to HIV infection.28 In reseach done by Allen et al.29 on HIV infection in urban Rwanda, the association between dyspareunia and nonmenstrual bleeding are often seen as signs and symptoms of undiagnosed venereal disease.29 In fact, in almost all of the research, genital lesions and ulcerations are discussed in the context of STD. The European study did report that in women with a history of candidiasis, the rate of HIV infection was significantly higher.30 As stated earlier and by many authors, included in the complications of HIV infection was significantly higher.30 As stated earlier and by many authors, included in the complications of FGM are severe dyspareunia, postcoital bleeding, ulceration and a high incidence of candidiasis.3,6,10,23,21,29 There is no conclusive evidence on the linkage of FGM to HIV transmission. However, Post31 describes an incident from a letter sent by the Minority Rights Group to Ammnesty International as follows: "While in Malawi a couple of months ago, I came across the story of a 14 year-old girl of Yao tribe that inhabits land in the Southern end of the country. She was diagnosed as HIV-positive although she was a virgin. Blame was laid on the fact that during tribal circumcision, the same razor would be used on any number of children at the same time."31 Perhaps future research on HIV transmission should include, as a variable, women who have had FGM performed because they also have genital ulcers and abrasions. If there were conclusive evidence linking FGM with the transmission of HIV, this may then become the best weapon in the arsenal for eradication of this practice.
OBSTETRICAL COMPLICATIONS
There are many obstetrical complications associated with infibulation, for the mother and fetus/baby. However, Mawad and other authors11 stress that with careful planning, good antenatal, intrapartum and postpartum care, most of these can be avoided. Some of the main complications are delayed second-stage labor, perineal tearing, vesicovaginal fistula, and low birth weight babies. It has been reported that some pregnant women reduce their dietary intake to avoid giving birth to large babies.32 The obstetrical management for those patients is important and often difficult for those that have not had this type of exposure.
The Norwich Park Hospital in the United Kingdom has established an "African Well Woman Clinic" with a specially trained staff and protocols in place for the management of the FGM women. The necessity for this arose because of the high influx of immigrants from the Sudan and Somalia. These areas in Africa are where infibulation is practiced on at least 95% of the women. On staff there is a female Somali translator and a Sudanese psychologist. Since the clinic's inception the number of persons visiting the clinic has risen from under 1% to almost 6%. In the research done by McCaffery on 50 of the patients that attended the clinic, 13 were nonpregnant, 14 were primigravida, and 23 multigravida. The main reason for the nonpregnant women's attendance was to request defibulation. At first visit the average gestational age was 15-20 weeks. Of the 14 primigravida patients, 7 had an adequate introitus to facilitate first- and second-stage labor. One patient had a deinfibulation done earlier, two requested antenatal deinfibulation and three preferred the procedure to be done at the time of delivery (one patient did not return to the clinic). Thirteen (93%) primigravida patients had vaginal deliveries, and all of these had either episiootomies or perineal lacerations. Fourteen (61%) multiparous had vaginal deliveries. Six (25.1%) had caesarean sections, and with three (13%) instrumentation was used. Included in this research is an excellent in-depth discussion of the problems encountered and the obstetrical management Two cases are discussed in detail. The first was a 26-year-old Sudanese (primigravida) presented at 26 weeks gestation with severe vulval itching. The introital opening measured less than 1 cm, so a speculum exam was not possible. A swab was passed and cultured Candida albicans. However, the insertion of the applicator for clotrimazole cream was not possible. Because of the severity of her symptoms, the woman underwent defibulation at 28 weeks' gestation and subsequently had a normal vaginal delivery.
For the infibulated mother in labor with a narrow introitus, the inability to do a vaginal exam to monitor progress, apply fetal scalp electrodes, or blood sampling are for the obstetrician mid-wife serous reasons for concern. The second case discussed was that of a 20-year-old Somali primigravida admitted with contractions at full term. The introitus barely admitted one finger and cardiotocography of the fetal heart showed 60 bpm without a contraction. An epidural anesthesia was administered to facilitate vaginal exam, and at this time the cervix was 2 cm dilated. Artificial rupture of the membrane was performed and revealed thick black meconium. The decision was made to perform a cesarean section. However a catherization could not be done, so deinfibulation was carried out to facilitate this.33 The author while in Saudia Arabia in 1980, found that a urethral catherization on the infibulated woman was quite difficult and unsuccessful at times due to extensive scar tissue, bands, and anatomical distortion. Valuable time can be lost in an emergency. The staff at the African Well Woman Clinic have developed a high level of expertise in caring for the infibulated woman, and from research it is evident that they have incorporated all aspects of well-being including psychological and cultural. The staff strongly recommends antenatal defibulation or elective reversal either before pregnancy, at 20 weeks gestation or if seen later in pregnancy than at 38 weeks. It takes about 1 week for the reversal to heal. This procedure should be performed under spinal anesthesia because the sensation of touch triggers flashbacks of the infibulation in childhood. In the nonpregnant women, general anesthesia is recommended.
LEGAL RAMIFICATIONS
Many countries such as Canada, England, Sweden, Australia, and others have enacted statutes prohibiting FGM and reinfibulation after delivery. In the United States a law was passed in 1997 which criminalizes FGM performed on a person who has not reached the age of 18 years but it does not address women older than 18 or reinfibulation after delivery. Infibulation was made illegal in Sudan in 1946 and still today nearly 90% of the women in Sudan have been subjected to FGM.24 Because FGM is now illegal, many young girls are taken out of the country to have it performed. The Center for Disease Control and Prevention estimates that there are over 150,000 females at risk in the United States for undergoing FGM.35 Clearly it will take more than legislation to eradicate this practice that can no longer be seen as a religious or traditional custom. One cannot mount an ethical defense for a practice that results in such a negative impact on a woman's health. This is not only a problem for countries where it is performed, but also for the Western Countries.
Health-care providers have an important role to fulfill in the eradication of this practice. We should act as advocates and increase professional and public awareness about such a practice, explaining the dangers and life-long disabilities it imposes. Perhaps the well-known crusader for eradication of FGM, who herself had this done, Merserak (Mimi) Ramsey, spoke for all women when she said, "This is a pain that doesn't go away. It is a lifetime wound,"36
REFERENCES
Dirie MA, Lindmark G. The risk of medical complications after female circumcision. East Afr Med J. 1992;62:479-482.
Council Report. Female genital mutilation. JAMA 1995;274(21):1714-1716.
El Dareer A. Complications of female circumcision in the Sudan. Trop Doct 1983;13:131-133 [PubMed]
Egwatu V, Agusa N. Complications of female circumcision in Nigerian Igbos. Br J Obstet Gynecol 1981;88:1090-1093. [Abstract]
Oyugi C. Social cultural factors that promote female circumcision and how this predisposes women to HIV infection. (Abst. 60067) Inter Conf on AIDS 1998;12:1011. [NLM Gateway]
Toubia N. a href="http://www.nejm.org/content/1994/0331/0011/0712.asp" target="_blank">Female circumcision as a public health measure. N Engl J Med 1994;331:712-716
Karungary K. Female genital mutilation: A reproductive health concern. Population Rep 1995:23:4. [PubMed]
Odoi A, Brody SP, Elkins RE. Female genital mutilation in rural Ghana, West Africa. Intern J Gynecaecol Obstet 1997;56:179-180.
Female genital mutilation in Nigeria. Lagos, Nigeria, Inter-African Committee on Practices Affecting the Health of Women and Children, Nigeria, 1997, 3. Monograph Series on Harmful and Beneficial Practices in Nigeria, no. 1.
Fox EF, de Ruiter A, Bingham S. Female genital mutilation. Intern J STD AIDS 1997;8:599-601. [PubMed]
Mawad NM, Hassanein OM. Female circumcision: Three years' experience of common complications in patients treated in Khartoum teaching hospitals. J Obstet Gynaecol 1994;14:40-43.
Black JA, DeBelle GD. Female genital mutilation in Britain. BMJ 1995;310:1590-1592.
Hanly GM, Objeda VJ. Epidermal inclusion cysts of the clitoris as a complication of female circumcision and pharonic infibulation. Cent Afr J Med 1995;41:22-24. [PubMed]
DeSilva S. Obstetric sequelae of female circumcision. Eur J Obstet Gynaecol Reprod Biol 1989;32:233-240. [PubMed]
Rowe PJ. Worldwide patterns of infertility: Is Africa different? Lancet 1985;2:596-598. [PubMed]
Sami J. Female circumcision with special reference to the Sudan. Ann Trop Paediatr 1986;6:99-115.
Shandall A. Circumcision and infibulation of female. Sudan Med J 1976;5:178-212.
Rushwan H. Etiologic factor in pelvic inflammatory disease in Sudanese women. Am J Obstet Gynecol 1980;138:877-879.
Ozumba BC. Acquired gynetresia in Eastern Nigeria. Int J Gynaecol Obstet 1992;37:105-109. [PubMed]
Mutenbei IB, Mwesiga MK. The impact of obsolete traditions on HIV/AIDS rapid transmission in Africa: The case of compulsory circumcision on young girls in Tanzania. (Abst 23473). Int Conf on AIDS 1998;12:436. [NLM Gateway]
Linke U. AIDS in Africa. Science 1986;231:203.
Hrdy DB. Cultural practices contributing to the transmission of human immunodeficiency virus in Africa. Rev Infect Dis 1987;9(6):1109-1117.
Kun KE. Female genital mutilation: the potential for increased risk of HIV infection. Int J Gynecol Obstetr 1997;15:153-155.
Toubia N. Female genital mutilation and the responsibility of reproductive health professionals. Intern J Gynecol Obstet 1994;46:127-135.
Arbesman M, Kahler L, Buck G. Assessment of the impact of female circumcision on the gynecological genitourinary and obstetrical health problems of women from Somalia: Literature Review and Case Studies. Women Health 1993,20:27-42. [Abstract]
WHO Statistical Information System. AIDS/HIV Statistics, http://www.who.int/whois/index.html.
Moore M, Bomboko B, Bertrand W, Moumoulini A, Kashala TD. Distribution and determinants for risk behaviour of HIV infection among young adults in Zaire: A "KAP" study. (Abst. Th C 105) Int Conf AIDS 1990;6:160.
Piot P, Laga M. Genital ulcers, other sexually transmitted diseases, and the sexual transmission of HIV. BMJ 1989;298:623-624. [PubMed]
Allen S, Lindan C, et al. Human immunodeficiency virus infection in urban Rwanda. JAMA 1991;266:1657-1663. [Abstract]
European Study Groups on Heterosexual transmission of HIV. Comparison of female to male and male to female transmission of HIV in 563 stable couples. BMJ 1992;304:809-812.
Post MT. Female genital mutilation and the risk of HIV. Washington, DC: Academy for Educational Development, support for Analysis and Research in Africa, 1995;1-10.
Calder B, Brown Y, Rae D. Female circumcision/genital mutilation: Culturally sensitive care. Health Care Women Int 1993;331:712-716. [PubMed]
McCaffery M. Management of female genital mutilation: The Northwick Park Hospital experience. Br J Obstet Gynaecol 1995;102:787-790. [PubMed]
Paul B. Maternal mortality in Africa. Soc Sci Med 1993;37:745-752. [PubMed]
Golara M, Morris N, Gordon H. Prevention of genital tract trauma during labour and delivery in an African population following female genital mutilation. J Obstet Gynaecol 1998;18:49-51.
AJN Newsline. A nurse wins her battle to ban FGM. AJN 1996;69:71.
Address reprint requests to:
Margaret Brady
Hostos Community College
500 Grand Concourse
Bronx, NY 10451
E-mail: BradyFNP@aol.com
Comments:
Comment in: AIDS Patient Care STDS 1999 Dec;13(12):683-8
--------------------------------------------------------------------------------
Citation:
Brady M. Female genital mutilation: complications and risk of HIV transmission. Aids Patient Care STDS 1999;13(12):709-16.
Belief Systems Underlying FGM
Erroneous Belief Systems
Underlying
Female Genital Mutilation in Sub-Saharan Africa
and
Male Neonatal Circumcision in the United States:
a Brief Report Updated
Hanny Lightfoot-Klein
Presented at
The Third International Symposium on Circumcision,
University of Maryland, College Park, Maryland
May 22-25, 1994.
--------------------------------------------------------------------------------
Background
I first became aware of the existence of what at that time was still euphemistically called "female circumcision" in 1979. I was then a middle-aged school teacher on sabbatical, back-packing alone through some of the less frequented areas of sub-Saharan Africa, in search of I knew not what.
The effect of this eye opener being suddenly thrust upon me was so profound, that when I returned to the United States a number of months later, I retired from my job in order to devote myself full time to researching this subject. Thus began my quest for insight into the highly complex network of belief systems that underlie the continuing prevalence of this ancient and brutal blood ritual.
As things turned out, I was to continue trekking in and out of Africa in pursuit of this phenomenon for the next six years, painstakingly collecting my data by means of first-hand observation and in-depth interviews, whenever the opportunity to do so presented itself.
The Practices
In sub-Saharan Africa, female genital mutilation rituals have been customary for millennia, and tenaciously continue to hold sway on all social levels, even now, at the very close of the 20th Century.
The immediate and long-term effects of the ritual procedures perpetrated on African girls, generally well before puberty, are so devastating to their health and well being, that they all but destroy the quality of their lives.
Horrendous pain, massive bleeding and raging infection may be expected to result from the procedures themselves, which are still carried out in the majority of cases without even local anesthesia. Normal passage of urine and menstrual blood are rendered all but impossible by infibulation, a sewing up of the vaginal orifice, down to a match stick sized opening, after the child's clitoris and labia have been cut away. Urinary and menstrual debris accumulating behind this "chastity belt of skin and scar tissue" create a perfect breeding ground for infection. Events such as defloration and childbirth, when these infibulations must be forcibly torn or cut open, are once again fraught with pain, infection, and almost inevitably, massive and often fatal blood loss.
While accurate statistics on "circumcision" related deaths are unobtainable and can at best only be estimated, they are unquestionably proportionate to the wild squirming of frantic children under the knife, the use of unsterile instruments, inadequate for performing delicate surgery even under the best conditions, the unavailability of effective antibiotics, and the failing eyesight of old women performing the procedures under poor lighting conditions.
As I progressed more deeply into my study of the subject, I was to make a number of amazing discoveries. I learned that the number of women afflicted by these practices lay somewhere between an estimated 60 and 100 million, a figure so enormous that it was almost impossibly to grasp.
Equally shocking was the fact that this taboo subject had been so successfully hidden from outsiders that its mere existence was all but unknown to the Western World. Even when scraps of information regarding the current status of these blood rituals somehow managed to leak into medical journals, they had always been deprecated by African officials.
Such reports were laughingly dismissed as: "something that is still found sporadically only among the most primitive and isolated remnants of remote tribes, somewhere in the outback." These same officials insisted that all educated and mainstream Africans had many generations ago abandoned the practice. My manifold observations of women's genitalia in delivery rooms, where I had achieved access, ostensibly to watch births, proved the contrary to be true. Female genital mutilation had been carried out on every single one of these patients, without exception.
Attitudes and Belief Systems Underlying the Practices
Contrary to all my expectations, I discovered that this ancient custom as adhered to and defended most resolutely not by men, but by its survivors, the women elders. It was these women that insisted most vehemently on its perpetuation and it was they who also wielded the knife.
Among the elite, the mutilation was often plotted by "the grandmothers," and carried out at the first unguarded moment that presented itself, in spite of all efforts that the child's educated parents had exerted in order to prevent it.
To nearly all the population, male and female alike, the mere idea that a girl should not be "circumcised" was altogether unthinkable. Not only would such a girl find no one who would marry her, but it was generally believed that all sorts of evils in respect to her sexual behavior, her health, and even more importantly in these cultures, the health of her husband and babies, would inevitably follow.
Eighty-seven percent of men and 83 percent of women voiced their unqualified approval of the practice, according to Dareer's extensive statistical study in Sudan. Taking into consideration that these mutilations are illegal under current Sudanese law, it is almost inevitable that the true approval rate is far closer to 100 percent for both men and women.
I learned that only a tiny handful of the most highly educated Africans had any notion whatsoever that in most of the world "female circumcision" was not practiced at all. Certainly, in the part of sub-Saharan East Africa where I researched the topic most intensively, a vulva left in its natural state stigmatized the woman as a slave, a prostitute, an outcast, an unclean being unworthy of the honor of continuing a respected family lineage.
Among the many people in all walks of life that I interviewed on the subject of female genital mutilation in Sudan, the epicenter of the most extreme excisions and infibulations, there was a young veterinarian who related the following to me:
"It had simply never occurred to me that there was anything wrong with the practice. Nor had this apparently ever occurred to any of my contemporaries, with whom I had at one time or another discussed it. It was only when I studied at a European university and saw how much less complicated things were for women there, that I finally understood how terrible a thing it is."
The Western World
Upon my return to the United States at the end of my long, peripatetic research, I established contact with Dr. John Money, Professor Emeritus at Johns Hopkins University, who willingly became my scrupulously exacting mentor. Under his tutelage, I began to publish my findings in scientific journals, and in the course of events, presented the first of my many papers on the subject at the International Academy of Sexology, in Cambridge, England in 1984.
At this conference, I met Dr. Heino Meyer-Bahlberg, a sexologist of German origin, who added an important dimension to the rapidly expanding consciousness of a sexologist-in-the-making. Through conversing with him, I was made aware that penile circumcision, which is practiced routinely on male infants in United States hospitals, is not customary in most of the Western World. In point of fact, nearly the whole of Continental Europe has never practiced it at all.
Next I was made aware of Edward Wallerstein's ground-breaking, meticulously researched and documented monograph on male circumcision, published in 1980. It decried the previously unchallenged mass amputations of altogether healthy foreskins of male neonates in United States hospitals as a contemporary medical scandal without equal. Wallerstein vehemently denounced the practice as being not only medically unnecessary, but not even medically justifiable.
History of Male Circumcision in the English Speaking World
Male circumcision first arose in England during the early part of the 19th century as a "cure" for masturbation, to which a prescientific medical establishment attributed a plethora of diseases. For well over a century, circumcision's reign as a so- called "health measure" put 99% of all British male infants to the knife. By virtue of the mother country's example, the procedure had also been embraced with equal enthusiasm by the medical profession in the rest of the English speaking world, most notably in the United States.
By the 1940's, the British upper classes had virtually discontinued the practice of male circumcision. Interestingly enough, they had also been first to instigate it originally. This demonstrated the innovative first-in, first-out behavior, characteristic of the leaders of any given society, ultimately followed by the less advantaged, in stages and over a protracted period of time.
This predictable social phenomenon was unexpectedly accelerated when male neonatal circumcision virtually disappeared among the rest of England's population in the late 1940's. At this time, Britain's newly instituted, post-war Socialized Medicine System took effect. The reason for the truly dramatic abandonment of this by then deeply entrenched practice was almost ludicrously simple. The newly established medical insurance system had failed to include the procedure in its list of paid for surgeries.
In the course of events that followed, it soon became evident in England that all of the dire predictions of medical disasters believed to inevitably follow if the infant penis was left in its natural state were without foundation. In spite of this, circumcision continued to be practiced on newborns as a "health measure" in the United States hospitals as before.
The Common Denominator
While my personal concerns had long centered predominantly around women's issues, I had never been quite comfortable with the entire concept of infant male circumcision. I had long suspected that there was something basically very wrong with unanesthetized surgery performed on immobilized, screaming infants, no matter how much these aspects of the procedure had always been trivialized by its advocates. Much like my Sudanese veterinarian counterpart, I had never pushed my awareness in that direction sufficiently to formulate exactly what it was that on a gut level I sensed to be wrong. Being a product of my time, I had accepted, as young women of my era generally did, that this was "men's business," which I, as a woman, was incapable of understanding and, which in any event, did not concern me.
When my own son was born, an extremely difficult, prolonged and badly mismanaged in-hospital labor had already subject both of us to tremendous trauma, neither my husband nor I had any stomach to add yet further injury to our first-born by way of a religious circumcision on the eighth day of his life. It was left to my father to come sailing unto the scene, take over all arrangements, and make certain that the rite was performed to his satisfaction. Although the experience of three days and nights of labor without analgesic, followed by a Cesarean section had temporarily robbed me of all strength, I have never quite come to terms with not having been able to prevent this, although my son has never borne me any malice.
Over the years, the more insight I gained into the various forms of genital mutilation of children, both in the pre-scientific societies I studied in Africa and the technologically advanced United States, the more I was struck by the similarities in rationale structures invented and proliferated by both to justify such mutilations. These rationale structures served as well to trivialize and justify the damage they contrived to perpetrate upon the bodies and psyches of their non-consenting and defenseless offspring.
In brief, I present here some of the most striking among these similarities:
Clitoridectomy and Infibulation in Africa Infant Male Circumcision in North America
"She loses only a little piece of the clitoris, just the part that protrudes. The girl does not miss it. She can still feel, after all. There is hardly any pain. Women's pain thresholds are so much higher than men's." "It's only a little piece of skin. The baby does not feel any pain because his nervous system is not developed yet."
"The parts that are cut away are disgusting and hideous to look at. It is done for the beauty of the suture." "An uncircumcised penis is a real turn-off. Its disgusting. It looks like the penis of an animal."
"Female circumcision protects the health of a woman. Infibulation prevents the uterus from falling out [uterine prolapse]. It keeps her smelling so sweet that her husband will be pleased. If it is not done, she will stink and get worms in her vagina." "An uncircumcised penis causes urinary infections and penile cancer. It generates smegma and smegma stinks. A circumcised penis is more hygienic and oral sex with an uncircumcised penis is disgusting to women."
"An uncircumcised vulva is unclean and only the lowest prostitute would leave her daughter uncircumcised. No man would dream of marrying an unclean woman. He would be laughed at by everyone." "An uncircumcised penis is dirty and only the lowest class of people with no concept of hygiene leave their boys uncircumcised."
"Leaving a girl uncircumcised endangers both her husband and her baby. If the baby's head touches the uncut clitoris during birth, the baby will be born hydrocephalic [excess cranial fluid]. The milk of the mother will become poisonous. If a man's penis touches a woman's clitoris he will become impotent." "Men have an obligation to their wives to give up their foreskin. An uncircumcised penis will cause cervical cancer in women. It also spreads disease."
"A circumcised woman is sexually more pleasing to her husband. The tighter she is sewn, the more pleasure he has." "Circumcised men make better lovers because they have no more staying power than uncircumcised men."
"All the women in the world are circumcised. It is something that must be done. If there is pain, then that is part of a woman's lot in life." "Men in all the 'civilized' world are circumcised."
"Doctors do it, so it must be a good thing." "Doctors do it, so it must be a good thing."
Sudanese grandmother: "In some countries they only cut out the clitoris, but here we do it properly. We scrape our girls clean. If it is properly done, nothing is left, other than a scar. Everything has to be cut away." My own father, a physician, speaking of ritual circumcision inflicted upon my son: "It is a good thing that I was here to preside. He had quite a long foreskin. I made sure that we gave him a good tight circumcision."
35 year old Sudanese woman: "Yes, I have suffered from chronic pelvic infections and terrible pain for years now. You say that all if this is the result of my circumcision? But I was circumcised over 30 years ago! How can something that was done for me when I was four years old have anything to do with my health now?" 35 years old American male: "I have lost nearly all interest in sex. You might say that I'm becoming impotent. I don't seem to have much sensation in my penis anymore, and it is becoming more and more difficult for me to reach orgasm. You say that this is the result of my circumcision? That doesn't make any sense. I was circumcised 35 years ago, when I was a little boy. How can that affect me in any way now?"
Discussion
A detailed statistical analysis is not the purpose of this article. Yet, the beliefs I have listed above tend to be verbalized predictably, consistently and in formula-like recital, generally in a specific order, much like any other platitude. Example: "It's not the heat, it's the humidity." Example: (Response obtained consistently from historically non-circumcising tribal women when asked why they have now begun to mutilate their daughters:) "This is the modern and hygienic way that educated people do it." Example: (Response from American mothers:) "A circumcised penis is easier to keep clean. Besides we don't want him to be laughed at in the locker room."
I have just returned from Mainland China, where the ground-breaking First Sino-North American Symposium on Sexology took place in October of this year. I was one of 55 participating sexological delegates from the U.S.A., Canada, Mexico and the Netherlands. I was highly impressed by the Chinese doctors' advanced technology in the treatment of male sexual dysfunction, and their blending of certain aspects of traditional Chinese medicine with modern Western techniques. Female sexual dysfunction is not being studied as yet, as one might well have expected.
In addition to being impressed, I was also much saddened to find these same Chinese doctors to be embarrassed and evasive when asked to demonstrate their acupuncture techniques, which the Chinese medical establishment has begun to abandon as old fashioned (and which we in the West are busily learning how to use more and more effectively.) I was further saddened to be proudly informed that they have now begun to circumcise male infants, in the Western mode (very much along the lines of: "This is the modern and hygienic way that educated people do it.")
I introduced a cautionary note, hopefully serving to dampen their obvious enthusiasm for the newly adopted procedure, by informing them that recent preliminary research findings in the United States point to a significant degree of sexual dysfunction in later years among circumcised males. It might be best, I suggested, that they not go overboard in their zeal to be Westernized until the results of a larger study on the relationship between circumcision and later sexual dysfunction are known.
Such a relationship should come as no great surprise, once one is able to get past the "It's only skin" argument, and one concentrates instead on the functional analogues of male and female genital structures. The "It's only a little piece, the woman does not miss it" argument loses out very quickly with men when they are informed that the clitoris is analogous to the penis, and how would they feel about having "just a little piece" of their penis removed. By the same token, removal of the male foreskin is functionally analogous to removal of the female labia, whose function is to protect the clitoris and to keep it moist. The mere thought of an unprotected and dry clitoris would make any woman cringe. It is also highly unlikely that such a clitoris would have retained much of its original sensitivity by the time a woman reaches the age of 30.
Conclusion
One may well speculate on what mental shifts the victims of the painful and sexually mutilating procedures inflicted in infancy and early childhood discussed here must make in order to process and come to terms with what they have suffered. Such shifts must be understood if we are to also understand how these victims eventually arrive at the conclusion that what has been perpetrated upon their bodies has been necessary, to their personal benefit, and that the custom which has dictated that this be done to them, must at all costs be perpetuated.
References
Dareer, Asma el, (1982) Woman Why Do You Weep? London: Zed Press.
Lightfoot-Klein, Hanny, (1989) Prisoners of Ritual: An Odyssey Into Female Genital Circumcision in Africa, Binghamton, N.Y., Haworth Press.
Wallerstein, Edward (1980) Circumcision: An American Health Fallacy, New York, Springer Publishing Co.
Underlying
Female Genital Mutilation in Sub-Saharan Africa
and
Male Neonatal Circumcision in the United States:
a Brief Report Updated
Hanny Lightfoot-Klein
Presented at
The Third International Symposium on Circumcision,
University of Maryland, College Park, Maryland
May 22-25, 1994.
--------------------------------------------------------------------------------
Background
I first became aware of the existence of what at that time was still euphemistically called "female circumcision" in 1979. I was then a middle-aged school teacher on sabbatical, back-packing alone through some of the less frequented areas of sub-Saharan Africa, in search of I knew not what.
The effect of this eye opener being suddenly thrust upon me was so profound, that when I returned to the United States a number of months later, I retired from my job in order to devote myself full time to researching this subject. Thus began my quest for insight into the highly complex network of belief systems that underlie the continuing prevalence of this ancient and brutal blood ritual.
As things turned out, I was to continue trekking in and out of Africa in pursuit of this phenomenon for the next six years, painstakingly collecting my data by means of first-hand observation and in-depth interviews, whenever the opportunity to do so presented itself.
The Practices
In sub-Saharan Africa, female genital mutilation rituals have been customary for millennia, and tenaciously continue to hold sway on all social levels, even now, at the very close of the 20th Century.
The immediate and long-term effects of the ritual procedures perpetrated on African girls, generally well before puberty, are so devastating to their health and well being, that they all but destroy the quality of their lives.
Horrendous pain, massive bleeding and raging infection may be expected to result from the procedures themselves, which are still carried out in the majority of cases without even local anesthesia. Normal passage of urine and menstrual blood are rendered all but impossible by infibulation, a sewing up of the vaginal orifice, down to a match stick sized opening, after the child's clitoris and labia have been cut away. Urinary and menstrual debris accumulating behind this "chastity belt of skin and scar tissue" create a perfect breeding ground for infection. Events such as defloration and childbirth, when these infibulations must be forcibly torn or cut open, are once again fraught with pain, infection, and almost inevitably, massive and often fatal blood loss.
While accurate statistics on "circumcision" related deaths are unobtainable and can at best only be estimated, they are unquestionably proportionate to the wild squirming of frantic children under the knife, the use of unsterile instruments, inadequate for performing delicate surgery even under the best conditions, the unavailability of effective antibiotics, and the failing eyesight of old women performing the procedures under poor lighting conditions.
As I progressed more deeply into my study of the subject, I was to make a number of amazing discoveries. I learned that the number of women afflicted by these practices lay somewhere between an estimated 60 and 100 million, a figure so enormous that it was almost impossibly to grasp.
Equally shocking was the fact that this taboo subject had been so successfully hidden from outsiders that its mere existence was all but unknown to the Western World. Even when scraps of information regarding the current status of these blood rituals somehow managed to leak into medical journals, they had always been deprecated by African officials.
Such reports were laughingly dismissed as: "something that is still found sporadically only among the most primitive and isolated remnants of remote tribes, somewhere in the outback." These same officials insisted that all educated and mainstream Africans had many generations ago abandoned the practice. My manifold observations of women's genitalia in delivery rooms, where I had achieved access, ostensibly to watch births, proved the contrary to be true. Female genital mutilation had been carried out on every single one of these patients, without exception.
Attitudes and Belief Systems Underlying the Practices
Contrary to all my expectations, I discovered that this ancient custom as adhered to and defended most resolutely not by men, but by its survivors, the women elders. It was these women that insisted most vehemently on its perpetuation and it was they who also wielded the knife.
Among the elite, the mutilation was often plotted by "the grandmothers," and carried out at the first unguarded moment that presented itself, in spite of all efforts that the child's educated parents had exerted in order to prevent it.
To nearly all the population, male and female alike, the mere idea that a girl should not be "circumcised" was altogether unthinkable. Not only would such a girl find no one who would marry her, but it was generally believed that all sorts of evils in respect to her sexual behavior, her health, and even more importantly in these cultures, the health of her husband and babies, would inevitably follow.
Eighty-seven percent of men and 83 percent of women voiced their unqualified approval of the practice, according to Dareer's extensive statistical study in Sudan. Taking into consideration that these mutilations are illegal under current Sudanese law, it is almost inevitable that the true approval rate is far closer to 100 percent for both men and women.
I learned that only a tiny handful of the most highly educated Africans had any notion whatsoever that in most of the world "female circumcision" was not practiced at all. Certainly, in the part of sub-Saharan East Africa where I researched the topic most intensively, a vulva left in its natural state stigmatized the woman as a slave, a prostitute, an outcast, an unclean being unworthy of the honor of continuing a respected family lineage.
Among the many people in all walks of life that I interviewed on the subject of female genital mutilation in Sudan, the epicenter of the most extreme excisions and infibulations, there was a young veterinarian who related the following to me:
"It had simply never occurred to me that there was anything wrong with the practice. Nor had this apparently ever occurred to any of my contemporaries, with whom I had at one time or another discussed it. It was only when I studied at a European university and saw how much less complicated things were for women there, that I finally understood how terrible a thing it is."
The Western World
Upon my return to the United States at the end of my long, peripatetic research, I established contact with Dr. John Money, Professor Emeritus at Johns Hopkins University, who willingly became my scrupulously exacting mentor. Under his tutelage, I began to publish my findings in scientific journals, and in the course of events, presented the first of my many papers on the subject at the International Academy of Sexology, in Cambridge, England in 1984.
At this conference, I met Dr. Heino Meyer-Bahlberg, a sexologist of German origin, who added an important dimension to the rapidly expanding consciousness of a sexologist-in-the-making. Through conversing with him, I was made aware that penile circumcision, which is practiced routinely on male infants in United States hospitals, is not customary in most of the Western World. In point of fact, nearly the whole of Continental Europe has never practiced it at all.
Next I was made aware of Edward Wallerstein's ground-breaking, meticulously researched and documented monograph on male circumcision, published in 1980. It decried the previously unchallenged mass amputations of altogether healthy foreskins of male neonates in United States hospitals as a contemporary medical scandal without equal. Wallerstein vehemently denounced the practice as being not only medically unnecessary, but not even medically justifiable.
History of Male Circumcision in the English Speaking World
Male circumcision first arose in England during the early part of the 19th century as a "cure" for masturbation, to which a prescientific medical establishment attributed a plethora of diseases. For well over a century, circumcision's reign as a so- called "health measure" put 99% of all British male infants to the knife. By virtue of the mother country's example, the procedure had also been embraced with equal enthusiasm by the medical profession in the rest of the English speaking world, most notably in the United States.
By the 1940's, the British upper classes had virtually discontinued the practice of male circumcision. Interestingly enough, they had also been first to instigate it originally. This demonstrated the innovative first-in, first-out behavior, characteristic of the leaders of any given society, ultimately followed by the less advantaged, in stages and over a protracted period of time.
This predictable social phenomenon was unexpectedly accelerated when male neonatal circumcision virtually disappeared among the rest of England's population in the late 1940's. At this time, Britain's newly instituted, post-war Socialized Medicine System took effect. The reason for the truly dramatic abandonment of this by then deeply entrenched practice was almost ludicrously simple. The newly established medical insurance system had failed to include the procedure in its list of paid for surgeries.
In the course of events that followed, it soon became evident in England that all of the dire predictions of medical disasters believed to inevitably follow if the infant penis was left in its natural state were without foundation. In spite of this, circumcision continued to be practiced on newborns as a "health measure" in the United States hospitals as before.
The Common Denominator
While my personal concerns had long centered predominantly around women's issues, I had never been quite comfortable with the entire concept of infant male circumcision. I had long suspected that there was something basically very wrong with unanesthetized surgery performed on immobilized, screaming infants, no matter how much these aspects of the procedure had always been trivialized by its advocates. Much like my Sudanese veterinarian counterpart, I had never pushed my awareness in that direction sufficiently to formulate exactly what it was that on a gut level I sensed to be wrong. Being a product of my time, I had accepted, as young women of my era generally did, that this was "men's business," which I, as a woman, was incapable of understanding and, which in any event, did not concern me.
When my own son was born, an extremely difficult, prolonged and badly mismanaged in-hospital labor had already subject both of us to tremendous trauma, neither my husband nor I had any stomach to add yet further injury to our first-born by way of a religious circumcision on the eighth day of his life. It was left to my father to come sailing unto the scene, take over all arrangements, and make certain that the rite was performed to his satisfaction. Although the experience of three days and nights of labor without analgesic, followed by a Cesarean section had temporarily robbed me of all strength, I have never quite come to terms with not having been able to prevent this, although my son has never borne me any malice.
Over the years, the more insight I gained into the various forms of genital mutilation of children, both in the pre-scientific societies I studied in Africa and the technologically advanced United States, the more I was struck by the similarities in rationale structures invented and proliferated by both to justify such mutilations. These rationale structures served as well to trivialize and justify the damage they contrived to perpetrate upon the bodies and psyches of their non-consenting and defenseless offspring.
In brief, I present here some of the most striking among these similarities:
Clitoridectomy and Infibulation in Africa Infant Male Circumcision in North America
"She loses only a little piece of the clitoris, just the part that protrudes. The girl does not miss it. She can still feel, after all. There is hardly any pain. Women's pain thresholds are so much higher than men's." "It's only a little piece of skin. The baby does not feel any pain because his nervous system is not developed yet."
"The parts that are cut away are disgusting and hideous to look at. It is done for the beauty of the suture." "An uncircumcised penis is a real turn-off. Its disgusting. It looks like the penis of an animal."
"Female circumcision protects the health of a woman. Infibulation prevents the uterus from falling out [uterine prolapse]. It keeps her smelling so sweet that her husband will be pleased. If it is not done, she will stink and get worms in her vagina." "An uncircumcised penis causes urinary infections and penile cancer. It generates smegma and smegma stinks. A circumcised penis is more hygienic and oral sex with an uncircumcised penis is disgusting to women."
"An uncircumcised vulva is unclean and only the lowest prostitute would leave her daughter uncircumcised. No man would dream of marrying an unclean woman. He would be laughed at by everyone." "An uncircumcised penis is dirty and only the lowest class of people with no concept of hygiene leave their boys uncircumcised."
"Leaving a girl uncircumcised endangers both her husband and her baby. If the baby's head touches the uncut clitoris during birth, the baby will be born hydrocephalic [excess cranial fluid]. The milk of the mother will become poisonous. If a man's penis touches a woman's clitoris he will become impotent." "Men have an obligation to their wives to give up their foreskin. An uncircumcised penis will cause cervical cancer in women. It also spreads disease."
"A circumcised woman is sexually more pleasing to her husband. The tighter she is sewn, the more pleasure he has." "Circumcised men make better lovers because they have no more staying power than uncircumcised men."
"All the women in the world are circumcised. It is something that must be done. If there is pain, then that is part of a woman's lot in life." "Men in all the 'civilized' world are circumcised."
"Doctors do it, so it must be a good thing." "Doctors do it, so it must be a good thing."
Sudanese grandmother: "In some countries they only cut out the clitoris, but here we do it properly. We scrape our girls clean. If it is properly done, nothing is left, other than a scar. Everything has to be cut away." My own father, a physician, speaking of ritual circumcision inflicted upon my son: "It is a good thing that I was here to preside. He had quite a long foreskin. I made sure that we gave him a good tight circumcision."
35 year old Sudanese woman: "Yes, I have suffered from chronic pelvic infections and terrible pain for years now. You say that all if this is the result of my circumcision? But I was circumcised over 30 years ago! How can something that was done for me when I was four years old have anything to do with my health now?" 35 years old American male: "I have lost nearly all interest in sex. You might say that I'm becoming impotent. I don't seem to have much sensation in my penis anymore, and it is becoming more and more difficult for me to reach orgasm. You say that this is the result of my circumcision? That doesn't make any sense. I was circumcised 35 years ago, when I was a little boy. How can that affect me in any way now?"
Discussion
A detailed statistical analysis is not the purpose of this article. Yet, the beliefs I have listed above tend to be verbalized predictably, consistently and in formula-like recital, generally in a specific order, much like any other platitude. Example: "It's not the heat, it's the humidity." Example: (Response obtained consistently from historically non-circumcising tribal women when asked why they have now begun to mutilate their daughters:) "This is the modern and hygienic way that educated people do it." Example: (Response from American mothers:) "A circumcised penis is easier to keep clean. Besides we don't want him to be laughed at in the locker room."
I have just returned from Mainland China, where the ground-breaking First Sino-North American Symposium on Sexology took place in October of this year. I was one of 55 participating sexological delegates from the U.S.A., Canada, Mexico and the Netherlands. I was highly impressed by the Chinese doctors' advanced technology in the treatment of male sexual dysfunction, and their blending of certain aspects of traditional Chinese medicine with modern Western techniques. Female sexual dysfunction is not being studied as yet, as one might well have expected.
In addition to being impressed, I was also much saddened to find these same Chinese doctors to be embarrassed and evasive when asked to demonstrate their acupuncture techniques, which the Chinese medical establishment has begun to abandon as old fashioned (and which we in the West are busily learning how to use more and more effectively.) I was further saddened to be proudly informed that they have now begun to circumcise male infants, in the Western mode (very much along the lines of: "This is the modern and hygienic way that educated people do it.")
I introduced a cautionary note, hopefully serving to dampen their obvious enthusiasm for the newly adopted procedure, by informing them that recent preliminary research findings in the United States point to a significant degree of sexual dysfunction in later years among circumcised males. It might be best, I suggested, that they not go overboard in their zeal to be Westernized until the results of a larger study on the relationship between circumcision and later sexual dysfunction are known.
Such a relationship should come as no great surprise, once one is able to get past the "It's only skin" argument, and one concentrates instead on the functional analogues of male and female genital structures. The "It's only a little piece, the woman does not miss it" argument loses out very quickly with men when they are informed that the clitoris is analogous to the penis, and how would they feel about having "just a little piece" of their penis removed. By the same token, removal of the male foreskin is functionally analogous to removal of the female labia, whose function is to protect the clitoris and to keep it moist. The mere thought of an unprotected and dry clitoris would make any woman cringe. It is also highly unlikely that such a clitoris would have retained much of its original sensitivity by the time a woman reaches the age of 30.
Conclusion
One may well speculate on what mental shifts the victims of the painful and sexually mutilating procedures inflicted in infancy and early childhood discussed here must make in order to process and come to terms with what they have suffered. Such shifts must be understood if we are to also understand how these victims eventually arrive at the conclusion that what has been perpetrated upon their bodies has been necessary, to their personal benefit, and that the custom which has dictated that this be done to them, must at all costs be perpetuated.
References
Dareer, Asma el, (1982) Woman Why Do You Weep? London: Zed Press.
Lightfoot-Klein, Hanny, (1989) Prisoners of Ritual: An Odyssey Into Female Genital Circumcision in Africa, Binghamton, N.Y., Haworth Press.
Wallerstein, Edward (1980) Circumcision: An American Health Fallacy, New York, Springer Publishing Co.
NEWS
IRAN: Temporary Marriages Just a Way to Degrade Women - Critics
By Kimia Sanati
TEHRAN, Jun 26 (IPS) - A key Iranian minister calls ‘temporary marriages’ a pragmatic way to deal with young people’s sexual needs and to prevent prostitution, but a wide range of critics lambasts them as little more than ways to give religious sanction to practices that degrade women.
The debate about temporary marriages, called ‘sighe’ or ‘mot'e’ and which can last a few hours or decades, continues weeks after Iran’s interior minister, Mostafa Pour Mohammadi, called them ‘’God’s decree for the young people" on May 31.
"Temporary marriages must be bravely promoted. Islam is in no way indifferent to the needs of a fifteen year-old youth in whom God has placed the sex drive," Mohammadi was quoted as saying by the media.
Angry criticism about these marriages, done to allow sexual relations within a supposedly acceptable religious context, immediately poured in from women's rights activists, sociologists, and even from women officials known to be hardliners.
"Unmarried people are not interested in temporary marriages at all and it is mostly married men who take temporary wives," Fatemeh Ajorlou, a conservative female member of parliament, told the Iranian Students News Agency. "Many women are hurt seriously by entering temporary marriages and the harm affects not only the women themselves but also their families," she said.
According to the latest statistics, the average age of marriage in Iran has risen to 26.7 for men and 22.4 for women. The legal age for marriage is 18 for men and 15 for women in this country of 70 million people.
Some young people are finding it increasingly difficult to start families, and are attracted to the idea of temporary marriages in spite of the huge stigma attached to it. But for others, it remains taboo.
"A lot of young people have premarital sex of some sort nowadays. Virginity can be restored (through a surgical procedure that is illegal but quite often carried out) if a girl breaks up with her partner and wants to marry someone and she can afford a few hundred dollars," Elnaz, a 26-year-old office worker from a middle-class family here, told IPS. "Birth control is readily available everywhere so there is much less inhibition than before."
"Many families, including mine, are now quite tolerant of their daughters having boyfriends if there are any prospects of marriage later, but temporary marriage is another story," she said.
"My father would rather die than let me enter into a temporary marriage, even with my boyfriend of three years, because it clearly speaks of the intention to have sex. He won't even allow my brother to do this, because he considers any girl or woman who accepts to be temporarily married a prostitute," she said.
More traditional families do not allow premarital relations. Fatemeh, a 24-year-old theology student from one of Iran's western provinces, told IPS her father and brothers would kill her if they found out that she had a boyfriend, let alone go into a temporary marriage.
"They are very religious, but even so, they are not prepared to even hear of temporary marriage," said Fatemeh. "I'm religious myself and don't want to have sex out of wedlock. But maybe a temporary marriage can be a good way to get to know the person I want to marry better."
Under temporary marriages, practiced largely by Shiites and banned by most Sunni sects, there are no limits as to the number of temporary wives a man can take. Unlike in Sunni communities, having multiple permanent wives is quite rare among Iranian Shiites.
A temporary marriage does not have to have witnesses or be registered anywhere, although it is always possible to register a marriage with a notary.
Just an agreement between the parties involved and a few sentences uttered in Arabic, or even in one's own language, are enough for the temporary marriage to be done. The husband has the exclusive right to terminate the marriage at any point he wishes, even before the term is over and without the wife's consent.
Widely practised in Iran by married and more rarely by single men, temporary marriages are largely looked down upon by traditional Iranian society, even among the very religious. In nearly all cases, women who enter into temporary marriages are divorcees or widows.
Virgin women need have permission from their father or paternal grandfather to enter into such a marriage, and temporary marriages involving young unmarried women are quite uncommon except among the extremely needy.
Unlike the usual marriage, a temporary marriage does not create any financial obligations for the man, who is only obliged to pay an agreed amount of money as dowry to the woman at the time of marriage, upon being asked during the marriage or at the time of its termination.
"The reason many religious women oppose the idea of temporary marriages in spite of strong religious sanctioning is that to marry second (or more) permanent wives men are required to have the consent of their other permanent wife (or wives), but this is not needed in the case of taking temporary wives," Fatemeh added.
"They take this as a threat to the foundations of the family and they are quite right. Temporary marriage has always been exploited by men who can afford it to give religious cover to having mistresses," the theology student said.
In Iran, prostitution and illicit sex are serious crimes. Offenders can be flogged and jailed. A person found guilty of illicit sex four times can be punished by death, and adulterers will face death by stoning.
"Prostitution made look 'religiously clean' is an age-old practice here. Very short- term temporary marriages for sex, in return for the 'dowry' that the man pays, have long been used for the purpose," said a sociologist who asked not to be named.
"Prostitution can't be officially recognised due to religious reasons in a religious state like Iran. One of the reasons they are promoting temporary marriage is that they want to give religious cover to prostitution to be able to deal with the problems associated with it without having to name it what it really is," she pointed out. (END/2007)
By Kimia Sanati
TEHRAN, Jun 26 (IPS) - A key Iranian minister calls ‘temporary marriages’ a pragmatic way to deal with young people’s sexual needs and to prevent prostitution, but a wide range of critics lambasts them as little more than ways to give religious sanction to practices that degrade women.
The debate about temporary marriages, called ‘sighe’ or ‘mot'e’ and which can last a few hours or decades, continues weeks after Iran’s interior minister, Mostafa Pour Mohammadi, called them ‘’God’s decree for the young people" on May 31.
"Temporary marriages must be bravely promoted. Islam is in no way indifferent to the needs of a fifteen year-old youth in whom God has placed the sex drive," Mohammadi was quoted as saying by the media.
Angry criticism about these marriages, done to allow sexual relations within a supposedly acceptable religious context, immediately poured in from women's rights activists, sociologists, and even from women officials known to be hardliners.
"Unmarried people are not interested in temporary marriages at all and it is mostly married men who take temporary wives," Fatemeh Ajorlou, a conservative female member of parliament, told the Iranian Students News Agency. "Many women are hurt seriously by entering temporary marriages and the harm affects not only the women themselves but also their families," she said.
According to the latest statistics, the average age of marriage in Iran has risen to 26.7 for men and 22.4 for women. The legal age for marriage is 18 for men and 15 for women in this country of 70 million people.
Some young people are finding it increasingly difficult to start families, and are attracted to the idea of temporary marriages in spite of the huge stigma attached to it. But for others, it remains taboo.
"A lot of young people have premarital sex of some sort nowadays. Virginity can be restored (through a surgical procedure that is illegal but quite often carried out) if a girl breaks up with her partner and wants to marry someone and she can afford a few hundred dollars," Elnaz, a 26-year-old office worker from a middle-class family here, told IPS. "Birth control is readily available everywhere so there is much less inhibition than before."
"Many families, including mine, are now quite tolerant of their daughters having boyfriends if there are any prospects of marriage later, but temporary marriage is another story," she said.
"My father would rather die than let me enter into a temporary marriage, even with my boyfriend of three years, because it clearly speaks of the intention to have sex. He won't even allow my brother to do this, because he considers any girl or woman who accepts to be temporarily married a prostitute," she said.
More traditional families do not allow premarital relations. Fatemeh, a 24-year-old theology student from one of Iran's western provinces, told IPS her father and brothers would kill her if they found out that she had a boyfriend, let alone go into a temporary marriage.
"They are very religious, but even so, they are not prepared to even hear of temporary marriage," said Fatemeh. "I'm religious myself and don't want to have sex out of wedlock. But maybe a temporary marriage can be a good way to get to know the person I want to marry better."
Under temporary marriages, practiced largely by Shiites and banned by most Sunni sects, there are no limits as to the number of temporary wives a man can take. Unlike in Sunni communities, having multiple permanent wives is quite rare among Iranian Shiites.
A temporary marriage does not have to have witnesses or be registered anywhere, although it is always possible to register a marriage with a notary.
Just an agreement between the parties involved and a few sentences uttered in Arabic, or even in one's own language, are enough for the temporary marriage to be done. The husband has the exclusive right to terminate the marriage at any point he wishes, even before the term is over and without the wife's consent.
Widely practised in Iran by married and more rarely by single men, temporary marriages are largely looked down upon by traditional Iranian society, even among the very religious. In nearly all cases, women who enter into temporary marriages are divorcees or widows.
Virgin women need have permission from their father or paternal grandfather to enter into such a marriage, and temporary marriages involving young unmarried women are quite uncommon except among the extremely needy.
Unlike the usual marriage, a temporary marriage does not create any financial obligations for the man, who is only obliged to pay an agreed amount of money as dowry to the woman at the time of marriage, upon being asked during the marriage or at the time of its termination.
"The reason many religious women oppose the idea of temporary marriages in spite of strong religious sanctioning is that to marry second (or more) permanent wives men are required to have the consent of their other permanent wife (or wives), but this is not needed in the case of taking temporary wives," Fatemeh added.
"They take this as a threat to the foundations of the family and they are quite right. Temporary marriage has always been exploited by men who can afford it to give religious cover to having mistresses," the theology student said.
In Iran, prostitution and illicit sex are serious crimes. Offenders can be flogged and jailed. A person found guilty of illicit sex four times can be punished by death, and adulterers will face death by stoning.
"Prostitution made look 'religiously clean' is an age-old practice here. Very short- term temporary marriages for sex, in return for the 'dowry' that the man pays, have long been used for the purpose," said a sociologist who asked not to be named.
"Prostitution can't be officially recognised due to religious reasons in a religious state like Iran. One of the reasons they are promoting temporary marriage is that they want to give religious cover to prostitution to be able to deal with the problems associated with it without having to name it what it really is," she pointed out. (END/2007)
temporary marriages in Iran
Temporary Marriage (Sigheh)
A man (married or not), and an unmarried woman (virgin, divorced, or widowed) can enter a temporary marriage contract (sigheh or nekah-e monghate'e) in which both parties agree on the period of the relationship and the amount of compensation to be paid to the woman. This arrangement requires no witnesses, and no registration is needed. This form of temporary marriage, according to its proponents, is a measure for curbing free sex and controlling prostitution.
A man can have as many sigheh wives as he can afford, but the woman can be involved in no more than one such temporary relationship at any given time and cannot enter another contract before a waiting period (edda) of three months or two menstrual cycles elapse. This obligatory waiting period also applies to divorced women in permanent marriage and is intended to determine paternity in case the woman becomes pregnant (Haeri 1989). Sigheh has been very unpopular, particularly among the educated middle-class families and among women who tend to associate it with legalized prostitution. It is known to be practiced mainly by widowed or divorced women and is believed to be more common in theological seminaries and among the clergy (Haeri 1989).
A man (married or not), and an unmarried woman (virgin, divorced, or widowed) can enter a temporary marriage contract (sigheh or nekah-e monghate'e) in which both parties agree on the period of the relationship and the amount of compensation to be paid to the woman. This arrangement requires no witnesses, and no registration is needed. This form of temporary marriage, according to its proponents, is a measure for curbing free sex and controlling prostitution.
A man can have as many sigheh wives as he can afford, but the woman can be involved in no more than one such temporary relationship at any given time and cannot enter another contract before a waiting period (edda) of three months or two menstrual cycles elapse. This obligatory waiting period also applies to divorced women in permanent marriage and is intended to determine paternity in case the woman becomes pregnant (Haeri 1989). Sigheh has been very unpopular, particularly among the educated middle-class families and among women who tend to associate it with legalized prostitution. It is known to be practiced mainly by widowed or divorced women and is believed to be more common in theological seminaries and among the clergy (Haeri 1989).
Subscribe to:
Posts (Atom)
