Female genital mutilation

"FGM" redirects here. For other uses, see FGM (disambiguation).

Female genital mutilation

Road sign near Kapchorwa, Uganda, where FGM is outlawed but still practised by the Pokot, Sabiny and Tepeth people.
Description	Partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons
Areas practised	Most common in 27 countries in sub-Saharan and north-east Africa, as well as in Yemen and Iraqi Kurdistan
Numbers	125 million in those countries
Age performed	Weeks after birth to puberty and beyond
Prevalence As of 2013, according to UNICEF, FGM is concentrated in Somalia (98 percent of women affected), Guinea (96 percent), Djibouti (93 percent), Egypt (91 percent), Eritrea (89 percent), Mali (89 percent), Sierra Leone (88 percent), Sudan (88 percent), Gambia (76 percent), Burkina Faso (76 percent), Ethiopia (74 percent), Mauritania (69 percent), Liberia (66 percent), Guinea-Bissau (50 percent), Chad (44 percent), Côte d'Ivoire (38 percent), Kenya (27 percent), Nigeria (27 percent), Senegal (26 percent), Central African Republic (24 percent), Yemen (23 percent), United Republic of Tanzania (15 percent), Benin (13 percent), Iraq (8 percent), Ghana (4 percent), Togo (4 percent), Niger (2 percent), Cameroon (1 percent), and Uganda (1 percent).
Legislation FGM is outlawed in the following practising countries, as of 2013: Benin (2003), Burkina Faso (1996), Central African Republic (1966, amended 1996), Chad (2003), Côte d’Ivoire (1998), Djibouti (1995, amended 2009), Egypt (2008), Eritrea (2007), Ethiopia (2004), Ghana (1965, amended 2007), Guinea (1965, amended 2000), Guinea-Bissau (2011), Iraqi Kurdistan (2011), Kenya (2001, amended 2011), Mauritania (2005), Niger (2003), Nigeria, some states (1999–2006), Senegal (1999), Somalia (2012), Sudan, some states (2008–2009), Togo (1998), Uganda (2010), United Republic of Tanzania (1998), and Yemen (2001). It is also outlawed in 33 countries outside Africa and the Middle East, including across the European Union, North America, Scandinavia, Australia and New Zealand.

Female genital mutilation (FGM), also known as female genital cutting and female circumcision, is defined by the World Health Organization (WHO) as "all procedures that involve partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons." FGM is practised as a cultural ritual by ethnic groups in 27 countries in sub-Saharan and Northeast Africa, and to a lesser extent in Asia, the Middle East and within immigrant communities elsewhere. It is typically carried out, with or without anaesthesia, by a traditional circumciser using a knife or razor. The age of the girls varies from weeks after birth to puberty; in half the countries for which figures were available in 2013, most girls were cut before the age of five.

The practice involves one or more of several procedures, which vary according to the ethnic group. They include removal of all or part of the clitoris and clitoral hood; all or part of the clitoris and inner labia; and in its most severe form (infibulation) all or part of the inner and outer labia and the closure of the vagina. In this last procedure, which the WHO calls Type III FGM, a small hole is left for the passage of urine and menstrual blood, and the vagina is opened up for intercourse and childbirth. The health effects depend on the procedure but can include recurrent infections, chronic pain, cysts, an inability to get pregnant, complications during childbirth and fatal bleeding.

Around 125 million women and girls in Africa and the Middle East have undergone FGM. Over eight million have experienced Type III, which is most common in Djibouti, Eritrea, Ethiopia, Somalia and Sudan. The practice is an ethnic marker, rooted in gender inequality, ideas about purity, modesty and aesthetics, and attempts to control women's sexuality. It is supported by both women and men in countries that practise it, particularly by the women, who see it as a source of honour and authority, and an essential part of raising a daughter well.

FGM has been outlawed in most of the countries in which it occurs, but the laws are poorly enforced. There has been an international effort since the 1970s to eradicate the practice and in 2012 the United Nations General Assembly voted unanimously to take all necessary steps to end it. The opposition is not without its critics, particularly among anthropologists; Eric Silverman writes that FGM is one of anthropology's central moral topics, raising questions about pluralism and multiculturalism within a debate framed by colonial and post-colonial history.

Terminology

Samburu FGM ceremony in Laikipia plateau, northern Kenya, photographed by Louisa Kasdon in 2004.

The practice was mostly known as female circumcision (FC) until the early 1980s. The Kenya Missionary Council began calling it the sexual mutilation of women in 1929, following the lead of Marion Scott Stevenson (1871–1930), a Church of Scotland missionary. The term female genital mutilation was coined in the 1970s by Austrian-American feminist Fran Hosken (1920–2006), author of The Hosken Report: Genital and Sexual Mutilation of Females (1979). The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children began using that term in 1990, and the following year the WHO recommended it to the United Nations. It has since become the dominant term within the medical literature to differentiate the severity of the procedures from male circumcision, which involves removal of the foreskin. It is opposed by some commentators, including anthropologist Richard Shweder, who has called it a gratuitous and invidious label.

Other English terms in use include female genital cutting (FGC) and female genital mutilation/cutting (FGM/C). The term infibulation (Type III FGM) derives from the Roman practice of fastening a fibula or brooch across the outer labia of female slaves.

Terms in use in countries where FGM is predominantly practised are often associated with hygiene. Arabic terms include tahara in Egypt and tahur in Sudan (purification). In the Bambara language in Mali it is known as bolokoli ("washing your hands"), and in Igbo in Nigeria as isa aru ("having your bath"). In Muslim communities procedures other than Type III are known as sunna circumcision; the term sunna means following the tradition of Muhammad, although the procedures are not required by Islam. A sunna kashfa in Sudan involves cutting off half the clitoris. Excision (removal of the clitoris and labia) is known as xalaalays or gudniin in Somalia. Another term for procedures other than Type III is nuss ("half"), and a procedure similar to Type III, but where the inner labia are sewn together instead of the outer labia, is called al juwaniya ("the inside type") in Sudan. Type III is known as pharaonic circumcision in Sudan (tahur faraowniya, or "pharaonic purification") – a reference to the practice in Ancient Egypt under the Pharaohs – but as Sudanese circumcision in Egypt. It is known simply as qodob (to "sew up") in Somalia.

Procedures and health effects

Circumcisers, methods, age of girls

Anatomy of the vulva, showing the clitoral glans, clitoral crura, corpora cavernosa, and vestibular bulbs

The procedures are generally performed, with or without anaesthesia, by a traditional circumciser (a cutter or exciseuse), usually an older woman who also acts as the local midwife, or daya in Egypt. They are often conducted inside the girl's family home. They may also be performed by the local male barber, who assumes the role of health worker in some areas. Medical personnel are usually not involved, although a large percentage of FGM procedures in Egypt, Sudan and Kenya are carried out by health professionals, and in Egypt most are performed by physicians, often in people's homes.

When traditional circumcisers are involved, non-sterile cutting devices are likely to be used, including knives, razors, scissors, cut glass, sharpened rocks and fingernails. Cauterization is used in parts of Ethiopia. A nurse in Uganda, quoted in 2007 in The Lancet, said a circumciser would use one knife to cut up to 30 girls at a time. With Type III the wound may be sutured with surgical thread, or held closed with agave or acacia thorns. Depending on the involvement of healthcare professionals, any of the procedures may be conducted with a local or general anaesthetic, or with neither. The most recent data for Egypt, where medical personnel often carry out the procedure, showed that in 60 percent of cases a local anaesthetic was used, in 13 percent a general, and in 25 percent none (two percent were missing/don't know).

The age at which FGM is performed depends on the country; it ranges from shortly after birth to the teenage years. The variation in ages signals that the practice is usually not regarded as a rite of passage between childhood and adulthood. In half the countries for which there are data, most girls are cut before the age of five, including over 80 percent in Eritrea, Ghana, Mali, Mauritania and Nigeria. The percentage is reversed in Chad, Central African Republic, Egypt and Somalia, where over 80 percent are cut between the ages of five and 14. A 1997 survey found that 76 percent of girls in Yemen were cut within two weeks of birth.

Classification

Overview

Normal female anatomy and how FGM Types I–III differ from it

The procedure used varies according to ethnicity. Information about the procedures comes from anthropologists, local health workers, and from a series of surveys conducted by aid agencies since the late 1980s. The surveys are based on questionnaires completed by the women themselves, who have responded using 50 different terms for the procedures. Apart from the difficulty of comparing and translating these terms across different cultures and languages, the women may not be able to describe what was done to them, procedures vary according to practitioners, and there is considerable overlap between categories. As a result no typology is entirely accurate.

The WHO divides the main procedures into three categories, Types I–III (see image right). The organization maintains a fourth category, Type IV, for piercing the clitoris or prepuce (symbolic circumcision) and for miscellaneous procedures not related to FGM as a ritual, such as cutting into the vagina (gishiri cutting). A 2006 study, in which 255 girls and 282 women in Sudan were asked to describe their cutting and were then examined, suggested that there was significant under-reporting of the severity of the procedures because the subjects were confusing the WHO's Types II and III. UNICEF instead uses the following categories: (1) cut, no flesh removed (pricking); (2) cut, some flesh removed; (3) sewn closed; and (4) type not determined/unsure/doesn't know.

WHO Types I and II

The WHO's Type I is subdivided into two. Type Ia is the removal of the clitoral hood, which is rarely, if ever, performed alone. More common is Type Ib (clitoridectomy), the partial or total removal of the clitoris, along with the prepuce. Susan Izett and Nahid Toubia of RAINBO, in a 1998 report for the WHO, wrote: "the clitoris is held between the thumb and index finger, pulled out and amputated with one stroke of a sharp object. Bleeding is usually stopped by packing the wound with gauzes or other substances and applying a pressure bandage. Modern trained practitioners may insert one or two stitches around the clitoral artery to stop the bleeding."

Type II is partial or total removal of the clitoris and inner labia, with or without removal of the outer labia. Type II is known as excision in English, but in French excision refers to all forms of FGM.

WHO Type III

External image
Example of Type III FGM, Swiss Medical Weekly, January 2011.

Type III (infibulation) is the removal of all external genitalia and the fusing of the wound, leaving a small hole (2–3 mm) for the passage of urine and menstrual blood. The inner and outer labia are cut away, with or without excision of the clitoris. A pinhole is created by inserting something into the wound before it closes, such as a twig or rock salt. The wound may be sutured with surgical thread, or agave or acacia thorns may be used to hold the sides together; according to a 1982 study in Sudan, eggs or sugar might be used as an adhesive. The girl's legs are then tied from hip to ankle for 2–6 weeks until the tissue has bonded. Anthropologist Janice Boddy witnessed the infibulation in 1976 of two sisters in northern Sudan by a traditional circumciser using an anaesthetic:

A crowd of habobat (grandmothers) have gathered in the yard – not a man in sight. ... The girl lies docile on an angarib, beneath which smoulders incence in a cracked clay pot. Her hands and feet are stained with henna applied the night before. Several kinswomen support her torso; two others hold her legs apart. Miriam [the midwife] thrice injects her genitals with local anesthetic, then, in the silence of the next few moments, takes a small pair of scissors and quickly cuts away her clitoris and labia minora; the rejected tissue is caught in a bowl below the bed. ... I am surprised there is so little blood. ... Miriam staunches the flow with a white cotton cloth. She removes a surgical needle from her midwife's kit ... and threads it with suture. She sews together the girl's outer labia leaving a small opening at the vulva. After a liberal application of antiseptic the operation is over.

Women gently lift the sisters as their angaribs are spread with multicolored birishs, "red" bridal mats. The girls seem to be experiencing more shock than pain ... Amid trills of joyous ululations we adjourn to the courtyard for tea; the girls are also brought outside. There they are invested with the jirtig: ritual jewelry, perfumes, and cosmetic pastes worn to protect those whose reproductive ability is vulnerable to attack from malign spirits and the evil eye. The sisters wear bright new dresses, bridal shawls called garmosis (singular), and their family's gold. Relatives sprinkle guests with cologne, much as they would at a wedding ... Newly circumcised girls are referred to as little brides (arus); much that is done for a bride is done for them, but in a minor key. Importantly, they have now been rendered marriageable.

Boddy wrote that older women in Sudan recalled a procedure in which the circumciser would scrape away the external genitals with a straight razor, and with no anaesthetic. The infibulated woman's vulva is opened for sexual intercourse, by a penis or knife, and for childbirth. Hanny Lightfoot-Klein, a social psychologist, interviewed 300 Sudanese women and 100 Sudanese men in the 1980s and described the penetration by the men of their wives' infibulation:

The penetration of the bride's infibulation takes anywhere from 3 or 4 days to several months. Some men are unable to penetrate their wives at all (in my study over 15%), and the task is often accomplished by a midwife under conditions of great secrecy, since this reflects negatively on the man's potency. Some who are unable to penetrate their wives manage to get them pregnant in spite of the infibulation, and the woman's vaginal passage is then cut open to allow birth to take place. ... Those men who do manage to penetrate their wives do so often, or perhaps always, with the help of the "little knife." This creates a tear which they gradually rip more and more until the opening is sufficient to admit the penis. In some women, the scar tissue is so hardened and overgrown with keloidal formations that it can only be cut with very strong surgical scissors, as is reported by doctors who relate cases where they broke scalpels in the attempt.

Defibulation, or deinfibulation, reverses the closure of the vagina; this is performed before childbirth, or at the request of a woman seeking to have her genitals repaired. After giving birth, women may ask that the infibulation be restored. Reinfibulation may also be carried out if a woman's husband is travelling away from home for a protracted period, after divorce or to prepare elderly women for death.

WHO Type IV

A variety of procedures are known as Type IV, which the WHO defines as "all other harmful procedures to the female genitalia for non-medical purposes, for example, pricking, piercing, incising, scraping and cauterization." These range from ritual nicking of the clitoris (ritual circumcision) to gishiri cutting, angurya cutting, burning or scarring the genitals, and introducing substances into the vagina to tighten it. Labia stretching is also categorized as Type IV FGM; in Tanzania and the Congo girls are told to stretch the clitoris and labia minora every day for 2–3 weeks; an older woman uses sticks to hold the stretched parts in place. Gishiri cutting involves cutting the vagina's anterior (front) wall to enlarge it, and angurya cuts involve scraping tissue away from around the vagina. Another procedure is hymenotomy, the removal of a hymen regarded as too thick, which is practised by the Hausa in West Africa. The WHO does not include cosmetic procedures such as labiaplasty or procedures used in sex reassignment surgery within its FGM categories (see below).

Complications

FGM has no known health benefits. It has immediate and late complications, which depend on several factors: the type of FGM; the conditions in which the procedure took place and whether the practitioner had medical training; whether unsterilized or surgical single-use instruments were used; whether surgical thread was used instead of agave or acacia thorns; the availability of antibiotics; how small a hole was left for the passage of urine and menstrual blood; and whether the procedure was performed more than once (for example, to close an opening regarded as too wide or re-open one too small).

Immediate complications include fatal bleeding, acute urinary retention, urinary infection, wound infection, septicemia, tetanus and transmission of hepatitis or HIV if instruments are non-sterile or reused. It is not known how many girls and women die from the procedure; few records are kept, complications may not be recognized, and fatalities are rarely reported.

Late complications vary depending on the type of FGM performed. The formation of scars and keloids can lead to strictures, obstruction or fistula formation of the urinary and genital tracts. Urinary tract sequelae include damage to urethra and bladder with infections and incontinence. Genital tract sequelae include vaginal and pelvic infections, painful periods, pain during sexual intercourse and infertility. Complete obstruction of the vagina results in hematocolpos and hematometra. Other complications include epidermoid cysts that may become infected, neuroma formation, typically involving nerves that supplied the clitoris, and pelvic pain.

FGM may complicate pregnancy and place women at higher risk for obstetrical problems, which are more common with the more extensive FGM procedures. Thus, in women with Type III who have developed vesicovaginal or rectovaginal fistulae – holes that allow urine and faeces to seep into the vagina – it is difficult to obtain clear urine samples as part of prenatal care, making the diagnosis of conditions such as preeclampsia harder. Cervical evaluation during labour may be impeded and labour prolonged. Third-degree laceration, anal sphincter damage and emergency caesarean section are more common in women who have experienced FGM. Neonatal mortality is also increased. The WHO estimated that an additional 10–20 babies die per 1,000 deliveries as a result of FGM; the estimate was based on a 2006 study conducted on 28,393 women attending delivery wards at 28 obstetric centers in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan. In those settings all types of FGM were found to pose an increased risk of death to the baby: 15 percent higher for Type I, 32 percent for Type II and 55 percent for Type III.

Psychological complications include depression and post-traumatic stress disorder. In addition, feelings of shame and betrayal can develop when the women move outside their traditional circles and learn that their condition is not the norm. They are more likely to report painful sexual intercourse and reduced sexual feelings, but FGM does not necessarily destroy sexual desire in women. According to several studies in the 1980s and 1990s, women said they were able to enjoy sex, though the risk of sexual dysfunction was higher with Type III.

Prevalence

Further information: Prevalence of female genital mutilation by country

Prevalence of FGM in Africa. For more detailed maps, see Mackie and UNICEF 2013, p. 26.

Information about the prevalence of FGM has been collected since 1989 in a series of Demographic and Health Surveys and Multiple Indicator Cluster Surveys funded by the United States Agency for International Development (USAID) and the United Nations Children's Fund (UNICEF). In 2013 UNICEF published a report based on 70 of these surveys, indicating that FGM is concentrated in 27 African countries, as well as in Yemen and Iraqi Kurdistan, and that 125 million women and girls in those countries have been affected.

The practice is mostly found in what political scientist Gerry Mackie describes as an "intriguingly contiguous zone" in Africa, from Senegal in the west to Somalia in the east, and from Egypt in the north to Tanzania in the south, intersecting in Sudan. According to UNICEF, the top rates are in Somalia (with 98 percent of women affected), Guinea (96 percent), Djibouti (93 percent), Egypt (91 percent), Eritrea (89 percent), Mali (89 percent), Sierra Leone (88 percent), Sudan (88 percent), Gambia (76 percent), Burkina Faso (76 percent), Ethiopia (74 percent), Mauritania (69 percent), Liberia (66 percent), and Guinea-Bissau (50 percent).

Around one in five cases is in Egypt. Forty-five million women over the age of 15 who had experienced FGM were living in Egypt, Ethiopia and northern Sudan as of 2008, and nine million were in Nigeria. Most of the women experience Types I and II. Type III is predominant in Djibouti, Somalia and Sudan, and in areas of Eritrea and Ethiopia near those countries. USAID estimated in 2008 that around eight million women in Africa over the age of 15 were living with Type III.

Outside Africa FGM occurs in Yemen (23 percent prevalence), among the Kurds in Iraq (giving the country an overall prevalence rate of eight percent), Indonesia and Malaysia. It has been documented in India, among the Bedouin in Israel, the United Arab Emirates, and by anecdote in Colombia, Oman, Peru and Sri Lanka. There are indications that it is performed in Jordan and Saudi Arabia, although no nationally representative information is available for those countries. There are also immigrant communities that practise it in Australia and New Zealand, Europe, Scandinavia, the United States and Canada.

In 2013 UNICEF reported a downward trend in some countries. In Kenya and Tanzania women aged 45–49 years were three times more likely to have been cut than girls aged 15–19, and the rate among adolescents in Benin, Central African Republic, Iraq, Liberia and Nigeria had dropped by almost half. In 2005 the organization reported that the median age at which FGM was performed had fallen in Burkina Faso, Côte d’Ivoire, Egypt, Kenya and Mali. Possible explanations include that, in countries clamping down on the practice, it is easier to cut a younger child without being discovered, and that the younger the girls are, the less they can resist. An increase in immigration from countries which practice FGM has led to the introduction of FGM to European and North American societies. The number of women who have undergone FGM and migrated is difficult to estimate and includes traditional immigrants, refugees, asylum seekers, and illegal immigrant.

Reasons

Overview

A Dogon circumcision cave painting in Mali. The Dogon believe that clitoridectomy and male circumcision establish gender.

Practitioners see the circumcision rituals as joyful occasions that reinforce community values and ethnic boundaries, and the procedure as an essential element in raising a girl. Mackie compares FGM to footbinding, which was outlawed in China in 1911; he writes that, like FGM, footbinding was an ethnic marker carried out on young girls, was nearly universal where practised, controlled sexual access to women, was tied to ideas about honour, appropriate marriage, health, fertility and aesthetics, was supposed to enhance male sexual pleasure, and was supported by the women themselves.

Among the reasons practitioners cite as benefits of FGM, according to UNICEF in 2013, are hygiene, social acceptance, marriageability, preservation of virginity/reduction of female sexual desire, male sexual pleasure, and religious requirement. Infibulation is said by several sources to enhance male sexual pleasure; Gruenbaum reports that men seem to enjoy the effort of penetrating their wife's infibulation.

Most often cited is the promotion of female virginity and fidelity. Infibulation almost guarantees monogamy because of the pain associated with sex and the difficulty of opening an infibulation without being discovered. According to philosopher Martha Nussbaum, uncircumcised women are seen as highly sexualized, in that the practice presupposes women to be "whorish and childish." The primary sexual concerns vary between communities. Rahman and Toubia write that the focus in Egypt, Sudan and Somalia is on curbing premarital sex, whereas in Kenya and Uganda the purpose is to reduce a woman's sexual desire so that her husband can more easily take several wives. In both cases, they argue, the aim is to serve the interests of male sexuality.

Female genitals are regarded within communities that practise FGM as dirty and ugly; physicians Miriam Martinelli and Jaume Enric Ollé-Goig write that the preference is for women's genitalia to be "flat, rigid and dry." The animist Dogon people of Mali believe that the clitoris confers masculinity on a girl and the foreskin of a boy makes him feminine, and perform FGM to differentiate more clearly between the genders. There are also various myths about the clitoris: that it will keep on growing, will harm a baby if it comes into contact with the baby's head, and can make men impotent. A more practical reason for FGM's continuance is that the circumcisers rely to some extent on the practice for their living.

Support from women

In the rural Egyptian hamlet where we have conducted fieldwork some women were not familiar with groups that did not circumcise their girls. When they learned that the female researcher was not circumcised their response was disgust mixed with joking laughter. They wondered how she could have thus gotten married and questioned how her mother could have neglected such an important part of her preparation for womanhood.

— Sandra D. Lane and Robert A. Rubinstein, 1996

A 1988 poem by Somali woman Dahabo Musa described infibulation as the "three feminine sorrows": the procedure itself, the wedding night when the woman has to be cut open, then childbirth when she has to be cut again. Despite the abundant literature on the suffering of women with FGM, particularly infibulation, it is usually the mothers and grandmothers who organize the procedure. Gerry Mackie and John LeJeune write that the women's support for the practice remains one of its "chief puzzles."

Mackie calls the support a "belief trap": "a belief that cannot be revised because the costs of testing [it] are too high." The cost of dissent in the case of FGM, he writes, is that the dissenters may fail to have descendants, because women who have not been circumcised may become outcasts and less likely to find husbands. Sociologist Elizabeth Heger Boyle writes that, in Tanzania, the Masai will not call an uncircumcised woman "mother" when she has children, and in several communities uncut women may not be allowed to attend funerals and other public events. According to UNICEF in 2013, the most recent surveys show that the majority of women in Mali, Guinea, Sierra Leone, Somalia, Gambia and Egypt believe the practice should continue, although elsewhere in Africa, Iraq and Yemen, most think it should end.

Support for Type III FGM also comes from women. Anthropologist Rose Oldfield Hayes reported in 1975 that educated Sudanese men living in cities who did not want to have their daughters infibulated – wanting to opt instead for clitoridectomy – would find the girls had been sewn up after their grandmothers arranged a supposed visit to relatives. Nearly 59 percent of 3,210 Sudanese women in a 1982 study by physician Asma El Dareer said they preferred Types II and III over Type I, and only 17.4 percent said they preferred none. Women in Sudan discussing circumcision with Janice Boddy in 1984 depicted Type I by opening their mouths and Type III by closing them tight, asking her: "Which is better, an ugly opening or a dignified closure?" Boddy wrote that the women avoided being photographed laughing or smiling for the same reason, preferring human orifices to be kept closed or minimized, particularly female ones. Izett and Toubia write that any change to the state of a woman's infibulation can affect her sense of identity and security. They cite the case of a Somali mother of three who was advised to remain defibulated after childbirth to cure her gonorrhoea, but who insisted on being reinfibulated, leading to pain and infection so severe she could hardly walk. They argue that she did this out of "her own sense of impurity."

Religion

Further information: Religious views on female genital mutilation

There is no mention of FGM in the Bible or Quran. Although its origins are pre-Islamic, it became associated with Islam because of that religion's focus on female modesty and chastity, and is found only within or near Muslim communities. It is praised in several hadith (sayings attributed to Muhammad) as noble but not required, along with advice that the milder forms are kinder to women. In 2006 several leading Islamic scholars called for an end to the practice, and in 2007 the Al-Azhar Supreme Council of Islamic Research in Cairo ruled that it has no basis in Islamic law. According to Mackie, it is not practised in Mecca and Medina in Saudi Arabia, Islam's holiest cities, although there have been reports of it in that country, perhaps among immigrant communities. Surveys have shown that there is a widespread belief in several countries, particularly Eritrea, Egypt, Guinea, Mali and Mauritania, that FGM is a religious requirement. Mackie and LeJeune write that practitioners may not distinguish between religion, tradition and chastity, which makes it difficult to interpret the data.

Outside Islam, FGM has been practised by the Christian Copts in Egypt and Sudan, and by the Beta Israel of Ethiopia, the only Jewish group known to have practised it. Judaism requires male circumcision, but does not allow FGM.

History and opposition

Origins in Africa

But if a man wants to know how to live, he should recite it [a magical spell] every day, after his flesh has been rubbed with the b3d [an unknown substance] of an uncircumcised girl and the flakes of skin [šnft] of an uncircumcised bald man.

— Inscription on Egyptian sarcophagus
c. 1991–1786 BCE

The origins of the practice are obscure. There is a reference to it on the sarcophagus of Sit-hedjhotep, in the Egyptian Museum, dating back to Egypt's Middle Kingdom, c. 1991–1786 BCE (see right). The Greek geographer Strabo (c. 64 BCE – c. 23 CE) wrote of it after visiting Egypt around 25 BCE: "This is one of the customs most zealously pursued by them [the Egyptians]: to raise every child that is born and to circumcise the males and excise the females." The philosopher Philo of Alexandria (c. 20 BCE – 50 CE) contrasted the Egyptian practice with God's commandment in the Book of Genesis (c. 950–500 BCE) that boys be circumcised, writing: "the Egyptians by the custom of their country circumcise the marriageable youth and maid in the fourteenth (year) of their age, when the male begins to get seed, and the female to have a menstrual flow."

A hieroglyph of a woman in labour and the physical examination of mummies by Australian pathologist Grafton Elliot Smith (1871–1937) suggest that Type III was not performed in ancient Egypt, although as part of the mummification process, the skin of the outer labia was pulled toward the anus to form a covering over the pudendal cleft (possibly to prevent sexual violation), which gave the appearance of Type III. Smith wrote that soft tissues were often removed by embalmers, or had simply deteriorated, so that it was not possible to determine from the mummies whether Types I and II had been practised.

Egyptologist Mary Knight writes that there is only one extant reference from antiquity that suggests FGM might have been practised outside Egypt. Xanthus of Lydia wrote in a history of Lydia in the fifth century BCE: "The Lydians arrived at such a state of delicacy that they were even the first to 'castrate' their women." Knight argues from the context that "castrate" refers here to a form of sterilization.

Mackie writes that FGM in Africa became linked to the slave trade. The Egyptians took captives in the south to be used as slaves, and slaves from Sudan were exported through the Red Sea to the Persian Gulf. The English explorer William Browne (1768–1813) reported in 1799 that infibulation was carried out on slaves in Egypt to prevent pregnancy (although the Swedish ethnographer, Carl Gösta Widstrand, argued that the slave traders simply paid a higher price for women who were infibulated anyway), and the Portuguese missionary João dos Santos (d. 1622) wrote of a group in Mogadishu who had a "custome to sew up their Females, especially their slaves being young to make them unable for conception, which makes these slaves sell dearer, both for their chastitie, and for better confidence which their Masters put in them." Thus, Mackie argues, patterns of slavery across Africa account for the patterns of FGM found there, and "[a] practice associated with shameful female slavery came to stand for honor."

Europe and the United States

Isaac Baker Brown "set to work to remove the clitoris whenever he had the opportunity of doing so."

Gynaecologists in 19th-century Europe and the United States would also remove the clitoris for various reasons, including to treat masturbation, believing that the latter caused physical and mental disorders. The first reported clitoridectomy in the West was carried out in 1822 by Karl Ferdinand von Graefe (1787–1840), a surgeon in Berlin, on a teenage girl regarded as an "imbecile" who was masturbating.

Isaac Baker Brown (1812–1873), an English gynaecologist, president of the Medical Society of London, and co-founder of St. Mary's Hospital in London, believed that the "unnatural irritation" of the clitoris caused epilepsy, hysteria and mania, and "set to work to remove [it] whenever he had the opportunity of doing so," according to his obituary in the Medical Times and Gazette. He did this several times between 1859 and 1866, sometimes with removal of the inner labia too. When he published his views in a book, On the Curability of Certain Forms of Insanity, Epilepsy, Catalepsy, and Hysteria in Females (1866), doctors in London accused him of quackery, mutilation and operating without consent, and he died in poverty after being expelled from the Obstetrical Society the following year.

In the United States J. Marion Sims (1813–1883), regarded as the father of gynaecology – controversially so because of his experimental surgery on slaves – followed Brown's work, and in 1862 slit the neck of a woman's uterus and amputated her clitoris, "for the relief of the nervous or hysterical condition as recommended by Baker Brown," after she complained of period pain, convulsions and bladder problems. Sources differ as to when the last clitoridectomy was performed in the United States. G. J. Barker-Benfield writes that it continued until at least 1904 and perhaps into the 1920s. A 1985 paper in the Obstetrical & Gynecological Survey said it was performed into the 1960s to treat hysteria, erotomania and lesbianism.

Colonial opposition in Kenya

Further information: Female circumcision controversy (Kenya, 1929–1932)

Christian missionary Hulda Stumpf was circumcised and murdered in her home in 1930.

Protestant missionaries in Kenya, a British colony from 1895 until 1963, started compaigning against FGM in 1906. The practice was known by the Kikuyu, the country's main ethnic group, as irua for both girls and boys: excision (Type II) for girls and removal of the foreskin for boys. Regarded by the Kikuyu as an important ethnic marker, the practice became a focal point of the independence movement from the 1920s onwards. Unexcised women (irugu) were outcasts, unmarriageable and often ending up as prostitutes, so to ask the Kikuyu to give up irua was unthinkable. There was also a fear that Europeans were campaigning against it so they could marry uncircumcised girls and acquire more Kenyan land.

Then as now, support for the practice came from the women themselves. E. Mary Holding, a Methodist missionary in Meru, Kenya, described the irua ritual for the girls as an entirely female affair, organized by women's councils known as kiama gia ntonye ("the council of entering"). The circumcised girls' mothers were allowed to become members of these councils, a position of some authority, which was yet another reason to support the practice.

Such was the focus on FGM in Kenya that the 1929–1931 period became known in the country's historiography as the female circumcision controversy. A person's stance toward the practice became a test of loyalty, either to the Christian churches or to the Kikuyu Central Association. The Church Missionary Society led the opposition, and sought support from humanitarian and women's rights groups in London, where the issue was raised in the House of Commons. Hulda Stumpf (1867–1930), an American missionary who had opposed allowing girls in a home she administered to undergo FGM, was murdered in her bed in January 1930 after being circumcised by her attackers.

Jomo Kenyatta, Kenya's first prime minister, argued that FGM was an important institution.

The general secretary of the Kikuyu Central Association, Jomo Kenyatta (c. 1894–1978) – who became Kenya's first prime minister in 1963 and had earlier studied anthropology at the London School of Economics under Bronisław Malinowski (1884–1942) – wrote that, for the Kikuyu, the institution of FGM was the "conditio sine qua non of the whole teaching of tribal law, religion and morality." No Kikuyu man or woman, he said, would marry someone who was not circumcised. Kenyatta lived in London from February 1929 to September 1930, and visited Church of Scotland officials to discuss the church's stance toward FGM. He wrote in a letter to The Manchester Guardian around that time:

The real argument lies not in the defense of the general surgical operation or its details, but in the understanding of a very important fact in the tribal psychology of the Kikuyu – namely, that this operation is still regarded as the essence of an institution which has enormous educational, social moral and religious implications, quite apart from the operation itself. For the present it is impossible for a member of the tribe to imagine an initiation without clitoridoctomy [sic]. Therefore the surgical abolition of the surgical element in this custom means to the Kikuyu the abolition of the whole institution.

In 1956 the council of male elders (the Njuri Nchecke) in Meru, Kenya, announced a ban on FGM. Over the next three years, as an act of defiance, thousands of girls circumcised each other with razor blades, although examinations by medical officers showed that the procedures mostly consisted of minor cuts to the labia. The movement came to be known in Meru as Ngaitana ("I will circumcise myself"), so-called because the girls claimed to have cut themselves to avoid naming their friends. Historian Lynn Thomas describes the episode as significant in the history of FGM because it made clear that its apparent victims were in fact its perpetrators.

Growth of opposition

Benoîte Groult

Nawal El Saadawi

Fran Hosken

African physicians also began speaking out against FGM. The Egyptian Doctors' Society called for it to be banned in the 1920s, and surgeon Ali Ibrahim Pasha, the director of Cairo University, spoke out against it in 1928. An Egyptian medical journal, Al Doktor, criticized it in 1951, as did an Egyptian women's magazine, Hawwaa, in 1957. In 1958 it became illegal to perform FGM in any of Egypt's state-run health facilities. The United Nations asked the World Health Organization to investigate the practice in 1958, but the WHO declined, responding that it was a cultural issue, not a medical one.

In 1975 Rose Oldfield Hayes published a paper in the American Ethnologist about infibulation in north Sudan, bringing the issue to wider academic attention. The United Nations Decade for Women (1975–1985) offered a focal point for opposition, and feminists began speaking out against it, in a few cases echoing the accusatory language of the earlier colonial campaigns. French writer Benoîte Groult wrote about FGM in her Ainsi soit-elle (1975); British journalist Jill Tweedie (1936–1993) in The Guardian in 1976; Egyptian physician Nawal El Saadawi in The Hidden Face of Eve: Women in the Arab World (1977); American feminist Mary Daly (1928–2010) in her Gyn/ecology (1978); and Senegalese writer Awa Thiam in La parole aux négresses (1978).

Austrian-American feminist Fran Hosken (1920–2006) – who founded the Women's International Network in 1975 – began researching FGM in 1971 and in 1979 published The Hosken Report: Genital and Sexual Mutilation of Females, coining the term female genital mutilation. She was uncompromising in her criticism, calling FGM a "training ground for male violence" and the women "mentally castrated." She accused the women of "participating in the destruction of their own kind," and argued that infibulation "teaches male children that the most extreme forms of torture and brutality against women and girls is their absolute right and what is expected of real men."

In February 1979 the WHO and the government of Sudan organized a seminar, "Traditional Practices Affecting the Health of Women and Children," in Khartoum, and Hosken presented her research to it. The early focus on the health risks of FGM had led to a proposal from physicians for a milder form to be practised and carried out under medical supervision. Hosken urged the seminar to see FGM instead as a violation of the women's rights, no matter who carries it out. Hosken's language caused a rift between African women and Western feminists. During the UN's Mid-Decade Conference on Women in Copenhagen in July 1980, feminists clashed over several issues, including the treatment of the Palestinians and how to approach FGM. African women boycotted a session that featured Hosken, calling her views ethnocentric and insensitive. The French Association of Anthropologists published a statement in 1981, arguing that "a certain feminism resuscitates (today) the moralistic arrogance of yesterday's colonialism":

Let's stop making the Africans look like savages, let's stop imposing on them our models for living and now our models for pleasure, let's stop to perceive horror in others to better deny them in our society. For now to whom is the scandal benefiting? Isn't the barbarian the one who believes in barbarism?

Throughout the 1980s to the 2000s, several African and international bodies signalled their opposition to the practice. The Convention on the Elimination of All Forms of Discrimination against Women was adopted by the UN General Assembly in December 1979. The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children called for an end to FGM in 1984, as did the UN's World Conference on Human Rights in 1993, and the Fourth World Conference on Women in Beijing in 1995. In 1997 the World Health Organization, United Nations Children's Fund and United Nations Population Fund issued a joint statement declaring their opposition to it. In 2003 the United Nations began sponsoring an annual International Day of Zero Tolerance to Female Genital Mutilation, held every 6 February, and in July that year the African Union ratified the Maputo Protocol, guaranteeing certain rights for women, including an end to FGM.

In 2008 FGM was finally outlawed in Egypt. After the 1959 ban on FGM in state-run hospitals, the practice had continued elsewhere in the country, and in 1995 CNN broadcast images of a ten-year-old girl undergoing it in a barber's shop in Cairo. As a result the government reversed the 1959 ban so that physicians could carry it out, but in 2007 a 12-year-old girl died during an FGM procedure conducted by a physician in an illegal clinic. The Al-Azhar Supreme Council of Islamic Research, the highest religious authority in Egypt, ruled in response that FGM had no basis in core Islamic law, and this enabled the government to outlaw it entirely.

The UN General Assembly voted unanimously to condemn the practice in December 2012, and urged member states to take all necessary steps toward ending it. The 54 nations of the African Group introduced the text of the resolution. As of 2013 FGM is outlawed in 26 African countries. Outside Africa, FGM is also concentrated in Iraqi Kurdistan, which passed legislation against it in 2011. As in Europe and the rest of the world, enforcement of the legislation is poor, although there have been arrests in Burkina Faso and Egypt.

Law in non-practising countries

Further information: Prevalence of female genital mutilation by country § Legal status in other regions, and Tahirih Justice Center

As a result of immigration, the practice spread to Australia, Europe, North America and Scandinavia. Families who have immigrated from practising countries send their daughters there to undergo FGM, ostensibly to visit a relative, and in the UK there are reports that parents fly in "house doctors" to perform the procedure on multiple girls during the same ceremony in one of the family's homes. As of 2013 anti-FGM legislation had been passed by 33 countries outside Africa and the Middle East. Sweden banned the practice in 1982, the first Western country to do so. Several former colonial powers, including Belgium, Britain, France and the Netherlands, followed suit, either with new laws or by making it clear that FGM was covered by existing legislation. The practice is outlawed in Australia and New Zealand, across the European Union, in the United States, and under section 268 of the Criminal Code of Canada.

Canada was the first to recognize FGM as a form of persecution when it granted refugee status in 1994 to Khadra Hassan Farah, who fled Somalia with her 10-year-old daughter to avoid the girl being subjected to it. As of May 2012 there had been no prosecutions in Canada. There have been several prosecutions in France, where FGM is covered by a provision of the penal code punishing acts of violence against children that result in mutilation or disability. There are thought to be up to 30,000 women in France who have experienced FGM, and thousands of girls at risk. Colette Gallard, a French family-planning counsellor, writes that when it was first encountered there, the initial reaction was that Westerners ought not to intervene, and it took the deaths of two girls in 1982, one of them three months old, for that attitude to change. Between then and 2012 there were 40 trials, resulting in convictions against two practitioners and over 100 parents.

There were nearly 100,000 girls in England and Wales thought to be at risk of FGM as of 2007, according to the charity FORWARD. The Prohibition of Female Circumcision Act 1985 outlawed the procedure in the UK, and the Female Genital Mutilation Act 2003 and Prohibition of Female Genital Mutilation (Scotland) Act 2005 made it an offence to arrange it outside the country for British citizens or permanent residents. In June 2013 the British National Society for the Prevention of Cruelty to Children launched a 24-hour helpline for children at risk, and in March 2014 charges against two physicians were announced after they repaired FGM on a patient in London who had given birth.

In the United States the Centers for Disease Control estimated in 1997 that 168,000 girls living there had undergone FGM or were at risk. Fauziya Kasinga, a 19-year-old woman from Togo and member of the Tchamba-Kunsuntu ethnic group, was granted asylum in 1996 after leaving an arranged marriage to escape FGM, setting a precedent in US immigration law. Performing FGM on anyone under the age of 18 became illegal in 1997 with the Federal Prohibition of Female Genital Mutilation Act. The Transport for Female Genital Mutilation Act was passed in January 2013 and prohibits knowingly transporting a girl out of the country for the purpose of undergoing FGM. Khalid Adem, who emigrated from Ethiopia to Atlanta, Georgia, became the first person in the US to be convicted in an FGM case; he was sentenced to ten years in 2006 for having severed his two-year-old daughter's clitoris with a pair of scissors.

Criticism of the opposition

Challenges to the mainstream position

photograph

FGM eradicationists, including novelist Alice Walker, have been criticized for failing to respect the women's own desires and interests.

Anthropologist Eric Silverman wrote in 2004 that FGM was one of the "central moral topics of contemporary anthropology." Anthropologists have been criticized for adopting a pluralist or relativist stance rather than defending human rights, while eradicationists stand accused of cultural colonialism.

Ugandan law professor Sylvia Tamale argued in 2011 that the early Western opposition stemmed from a Judeo-Christian, voyeuristic judgment that African sexual culture, including not only FGM but also dry sex, polygyny and levirate marriage, consisted of primitive practices that required correction. Following the publication of Fran Hosken's report in 1979, Tamale wrote, opposition to FGM became an obsession of anthropologists and women's rights activists, who "flocked to the continent with the zeal of missionaries." She cautioned that African feminists object to the "imperialist, racist and dehumanising infantilization of African women." African-American feminists have also come into conflict with each other over FGM: Stanlie James criticized the writer and anti-FGM campaigner Alice Walker, calling her "'possessed' of the pernicious notion" that she has to save the African women from themselves.

Several anthropologists have challenged the international opposition to FGM, including Richard Shweder, Janice Boddy, Carla Obermeyer and Fuambai Ahmadu, who was herself cut as an adult when she was initiated into the Bundu secret society in Sierra Leone. Shweder argues that anthropologists who specialize in gender issues in Africa have long been aware of the discrepancies between their own experiences and the global discourse on FGM, which in his view has replaced critical thinking with political activism. The accuracy of the factual and moral claims against FGM are taken for granted to such an extent, he argues, that the practice has become an "obvious counterargument to cultural pluralism."

Shweder opposes the view of FGM as a human rights violation, arguing that there are no such things as natural rights, but maintains that if a rights perspective is adopted, it must take other rights into account, such as the right to self-determination, autonomy and freedom of religion. He highlights the Mandinka of Guinea-Bissau, for whom bodily integrity and purity are required for prayer, and are achieved by circumcision. He argues further that the medical evidence does not support the view of FGM as invariably harmful, citing reviews of the medical literature in 1999, 2003 and 2005 by medical anthropologist and epidemiologist Carla Obermeyer of Harvard University, who suggested that the more serious medical complications are relatively infrequent. Shweder also cites a 2001 study by Linda Morison of the London School of Hygiene and Tropical Medicine that looked at the reproductive health consequences of Type II FGM in the Gambia; Morison concluded that there were few differences between the circumcised and uncircumcised women.

Comparison with other procedures

Obermeyer argues that FGM may be conducive to women's well-being within their communities in the same way that procedures such as breast implants, rhinoplasty and male circumcision may help people in other cultures. The WHO does not include cosmetic procedures such as labiaplasty (reduction of the inner labia), vaginoplasty (tightening of the vaginal muscles) and clitoral hood reduction as examples of FGM; they write that some elective practices do fall within its categories, but its broad definition aims to avoid loopholes. Gynaecologist Birgitta Essén and anthropologist Sara Johnsdotter argue that this is a double standard, with adult African women (for example, those seeking reinfibulation after childbirth) viewed as mutilators trapped in a primitive culture, while other women seeking cosmetic genital surgery are viewed as exercising their right to control their own bodies.

Essén and Johnsdotter write that some doctors have drawn a parallel between cosmetic procedures and FGM. Ronán Conroy of the Royal College of Surgeons in Ireland argued in 2006 that cosmetic genital procedures are "driving the advance of female genital mutilation by promoting the fear in women that what is natural biological variation is a defect, a problem requiring the knife."

Martha Nussbaum argues that the key moral and legal issue with FGM is that it is conducted on children using physical force.

Some of the legislation banning FGM would seem to cover cosmetic genital alteration. The law in Sweden, for example, bans operations "on the external female genital organs which are designed to mutilate them or produce other permanent changes in them ... regardless of whether consent ... has or has not been given." Because anti-FGM laws are not used to stop cosmetic genital procedures, Essén and Johnsdotter argue that it seems the law distinguishes between Western and African female genitals, and deems only African women unfit to make their own decisions. Where FGM is banned even if consent is given, physicians may end up having to ask of prospective patients whether they appear to be victims of African patriarchy before deciding whether to offer them genital alteration.

Arguing against these parallels, philosopher Martha Nussbaum writes that the key issue with FGM is that it is mostly conducted on children using physical force. She argues that the distinction between social pressure, which might reduce autonomy, and physical force is always morally and legally salient, and is arguably comparable to the distinction between seduction and rape. She also argues that the literacy of women in practising countries is generally poorer than that of women in the Western world, which reduces their ability to make informed choices.

Several commentators argue that children's rights are being violated in the West too, with the genital alteration of intersex children born with genital anomalies that physicians regard as in need of correction. Legal scholars Nancy Ehrenreich and Mark Barr write that thousands of these procedures take place every year in the United States, and argue that they are medically unnecessary, more extensive than FGM, and have more serious physical and mental consequences. They attribute the silence of anti-FGM campaigners about intersex procedures to white privilege and North American exceptionalism, a refusal to acknowledge that "similar and harmful genital cutting occurs in their own backyards."

Notes

Sources are listed in long form on first reference and short form thereafter.

References

Books and papers are listed in the Notes section and repeated below; other sources are in the Notes section only.

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Further reading

Resources

• "Factsheet on FGM", World Health Organization, February 2013.
• End FGM campaign, Amnesty International.
• British National Society for the Prevention of Cruelty to Children 24-hour national helpline for children at risk of FGM: 0800 028 3550
• FORWARD, London, charity specializing in FGM research (FORWARD's list of hospitals and clinics in the UK offering specialist FGM services).
• Desert Flower Foundation ("First Desert Flower Center opens in Berlin", 16 September 2013; first dedicated FGM clinic in Europe).
• A/RES/48/104. Declaration on the Elimination of Violence against Women: Article 2: section (a)—Declaration on the Elimination of Violence Against Women

Bibliographies

• "Circumcision, female", The Kinsey Institute (bibliography 1960s–1980s).
• Westley, David M. "Female circumcision and infibulation in Africa", Electronic Journal of Africana Bibliography, 4, 1999 (bibliography up to 1997).

Books and news

• Gollaher, David. Circumcision: A History of the World's Most Controversial Surgery, Basic Books, 2000.
• CNN. Report on FGM in Egypt, February 2009.
• Guardian. FGM archive; Guardian interactive, 22 July 2013.
• Haworth, Abigail. "The day I saw 248 girls suffering genital mutilation", The Guardian, 18 November 2012.
• Sembène, Ousmane. Moolaadé, 2004, a film about abandoning FGM.
• Sinclair, Stephanie. '"Inside a Female-Circumcision Ceremony", The New York Times magazine, April 2006, slideshow of images from Indonesia (article).
• Walker, Alice. Possessing the Secret of Joy, New Press, 1993 (novel).
• UNICEF. "Towards the abandonment of female genital mutilation in five African countries", October 2010.

Personal stories

• Ali, Ayaan Hirsi. Infidel: My Life, Simon & Schuster, 2007: Ali experiences FGM at the hands of her grandmother.
• Dirie, Waris. Desert Flower, Harper Perennial, 1999: autobiographical novel.
• Dirie, Waris. Desert Dawn, Little, Brown, 2003: Dirie's work as UN Special Ambassador against FGM.
• Dirie, Waris. Desert Children, Virago, 2007: FGM in Europe
• Kasinga, Fauziya, and Bashir, Layli Miller. Do They Hear You When You Cry, Delacorte Press, 1998.
• El Saadawi, Nawal. Woman at Point Zero, Zed Books, 1975.