Female genital mutilation

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

Road sign near Kapchorwa, Uganda, 2004. FGM was outlawed there in 2009, but is still practised by the Pokot, Sabiny and Tepeth people.
Description	Defined by the WHO, UNICEF and UNFPA as the "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	Days after birth to puberty and beyond
Prevalence Figures 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) Uganda (1 percent).
Legislation Laws As of 2013 there is legislation in place against FGM in the following practising countries (several have introduced restrictions short of a ban; an asterisk indicates a ban according to UNICEF–UNFPA in 2012): 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) Tanzania (1998) Togo (1998) Uganda (2010*) Yemen (2001). FGM is outlawed in 33 countries outside Africa and the Middle East, including across the European Union, Scandinavia, North America, Australia and New Zealand.

Female genital mutilation (FGM), also known as female genital cutting and female circumcision, is the ritual removal of some or all of the external female genitalia. Typically carried out by a traditional circumciser with a blade or razor, with or without anaesthesia, FGM is practised by ethnic groups in 27 countries in sub-Saharan and north-east Africa, in Yemen and Iraqi Kurdistan, and to a lesser extent elsewhere in Asia and within immigrant communities around the world. The age at which it is conducted varies from days after birth to puberty; in half the countries for which national figures were available in 2000–2010, most girls were cut before the age of five.

The procedures differ according to the ethnic group. They include removal of the clitoral hood and part of the clitoris, and removal of the clitoris and inner labia. In the most severe form (known as infibulation), the inner and outer labia are removed and the vulva is closed; a small hole is left for the passage of urine and menstrual blood, and the vagina is opened for intercourse and childbirth. 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. There are no known health benefits.

The practice is rooted in gender inequality, attempts to control women's sexuality, and ideas about purity, modesty and aesthetics. It is usually initiated and carried out by women, who see it as a source of honour, and who fear that failing to have their daughters and granddaughters cut will expose the girls to social exclusion. Over 125 million women and girls have experienced FGM in Africa, Yemen and Iraqi Kurdistan; half of them live in Egypt and Ethiopia. Over eight million women and girls have been infibulated, a practice most common in Djibouti, Eritrea, Ethiopia, Somalia and Sudan.

FGM has been outlawed or restricted in most of the countries in which it occurs, but the laws are poorly enforced. There have been international efforts since the 1970s to persuade practitioners to abandon it, and in 2012 the United Nations General Assembly voted unanimously to intensify those efforts. The opposition is not without its critics, particularly among anthropologists. Eric Silverman writes that FGM has become one of anthropology's central moral topics, raising difficult questions about cultural relativism, tolerance and the universality of human rights.

Terminology

English

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

Until the 1980s FGM was widely known in English as "female circumcision," which implied an equivalence in severity with male circumcision. In 1929 the Kenya Missionary Council began referring to it as the "sexual mutilation of women," following the lead of Marion Scott Stevenson, a Church of Scotland missionary. References to it as mutilation increased as opposition grew throughout the 1970s. Anthropologist Rose Oldfield Hayes used the term "female genital mutilation" in 1975 in the title of a paper, and in 1979 Austrian-American researcher Fran Hosken called it mutilation in her influential The Hosken Report: Genital and Sexual Mutilation of Females.

The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children began calling it female genital mutilation in 1990, as did the World Health Organization (WHO) the following year. In April 1997 the WHO, the United Nations Children's Fund (UNICEF) and the United Nations Population Fund (UNFPA) issued a statement defining FGM as "all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or other non-therapeutic reasons." That term is now widely used and is dominant within the medical literature. Other terms include female genital cutting (FGC) and female genital mutilation/cutting (FGM/C), often used by those working with practitioners.

Local terms

The many variants of FGM, which depend on the ethnic group and individual practitioner, are reflected in dozens of local terms in countries where it is common; women in Niger responded to a survey in 1998 using 50 different terms. These often refer to purification. A common Arabic term for purification has the root t-h-r, used for both male and female circumcision (tahur and tahara). In the Bambara language in Mali FGM is known as bolokoli ("washing your hands") and in the Igbo language in Nigeria as isa aru ("having your bath").

The mildest form (clitoridectomy) is widely known as sunna circumcision; sunna means following the tradition of Muhammad, although the procedure is not required by Islam. A sunna kashfa in Sudan, for example, involves removing half the clitoris. Nuss ("half") in Sudan is for anything between clitoridectomy and infibulation, and juwaniya ("the inside type") is where only the inner labia are sewn together. In Somalia removal of the clitoris and inner labia is known as xalaalays or gudniin.

The term infibulation derives from fibula, Latin for pin or clasp, and is said to refer to the Ancient Roman practice of fastening a clasp across the labia of female slaves. Infibulation is known as tahur faraowniya ("pharaonic purification") in Sudan, but as "Sudanese circumcision" in Egypt. In Somalia it is known simply as qodob ("to sew up").

Procedures, health effects

Circumcisers, methods, ages

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

The procedures are generally performed by a traditional circumciser, with or without anaesthesia, often in the girl's home. The circumciser is usually an older woman who may also be the local midwife; in communities where the male barber has assumed the role of health worker, he will perform FGM too. Medical personnel are usually not involved, although in some countries, particularly Egypt, Sudan and Kenya, FGM is more likely to be carried out by health professionals. Surveys in Egypt in 1997–2011 indicated that 77 percent of procedures were performed by medical professionals, often physicians.

When traditional circumcisers are involved, non-sterile cutting devices are likely to be used, including knives, razors, scissors, 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.

Depending on the involvement of healthcare professionals, the procedures may include a local or general anaesthetic, or neither. According to UNICEF in 2013, women in Egypt reported in 1995 that a local anaesthetic was used on their daughters in 60 percent of cases, a general in 13 percent, and neither in 25 percent (two percent were missing/don't know). Given the higher-than-usual involvement of physicians in FGM in that country, the percentage of procedures performed without anaesthesia is likely to be higher elsewhere.

The age at which FGM is performed ranges from shortly after birth to the teenage years. The variation signals that it is often not 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 Nigeria, Mali, Eritrea, Ghana and Mauritania. The percentage is reversed in Somalia, Egypt, Chad and the Central African Republic, 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 procedures vary according to ethnicity and individual practitioners. The difficulty of collecting accurate data across so many countries means that none of the typologies are entirely accurate. The aid agencies have created them based on household surveys known as Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS); these have been conducted in Africa roughly every five years, since 1984 and 1995 respectively. The questionnaires are completed by women aged 15–49.

In one survey in Niger in 1998, the women responded with 50 different terms when asked to describe what was done to them in their own language. Translation problems are compounded by confusion over which procedure was experienced. In a 2006 study in Sudan, in which over 500 subjects were asked to describe their procedure before being examined, a significant percentage of infibulated subjects reported a lesser procedure.

UNICEF divides FGM into four categories: (1) cut, no flesh removed (pricking or symbolic circumcision); (2) cut, some flesh removed; (3) sewn closed; and (4) type not determined/unsure/doesn't know. The WHO categorizes the main procedures as Types I–III, and Type IV for symbolic circumcision and miscellaneous procedures.

WHO Types I and II

Most women who undergo FGM experience WHO Types I or II. Type I is further divided into Ia, the removal of the clitoral hood (rarely, if ever performed alone), and the more common Ib (clitoridectomy), the partial or total removal of the clitoris and clitoral hood.

[T]he 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.

— Susan Izett, Nahid Toubia (WHO), 1998

Type II (excision) is the partial or total removal of the clitoris and inner labia, with or without removal of the outer labia. (The term excision in French often refers to any form of FGM.)

Type III

External image

Type IIIb FGM

— Swiss Medical Weekly, January 2011

Type III (infibulation) is the removal of all the external genitalia and the fusion of the wound. The inner and/or outer labia are cut away, with or without removal of the clitoris. Type IIIa is the removal and fusion of the inner labia, and Type IIIb of the outer labia.

A single 2–5 mm-hole is left for the passage of urine and menstrual blood by inserting something into the wound. The vulva is then closed with surgical thread, agave or acacia thorns, or a poultice of raw egg, herbs and sugar. The girl's legs are tied together to help the tissue bond; the bindings are loosened after a week and usually removed after two. The parts that have been removed might be placed in a pouch for the girl to wear. Comfort Momoh, a specialist midwife in England, describes an infibulation:

[E]lderly women, relatives and friends secure the girl in the lithotomy position. A deep incision is made rapidly on either side from the root of the clitoris to the fourchette, and a single cut of the razor excises the clitoris and both the labia majora and labia minora.

Bleeding is profuse, but is usually controlled by the application of various poultices, the threading of the edges of the skin with thorns, or clasping them between the edges of a split cane. A piece of twig is inserted between the edges of the skin to ensure a patent foramen for urinary and menstrual flow. The lower limbs are then bound together for 2–6 weeks to promote haemostatis and encourage union of the two sides ...

Healing takes place by primary intention, and, as a result, the introitus is obliterated by a drum of skin extending across the orifice except for a small hole. Circumstances at the time may vary; the girl may struggle ferociously, in which case the incisions may become uncontrolled and haphazard. The girl may be pinned down so firmly that bones may fracture.

Type III FGM is concentrated in Djibouti, Eritrea, Ethiopia, Somalia and Sudan; about eight million women in Africa, 15 years and older, have experienced it. The vulva is opened with a penis or knife for sexual intercourse. Psychologist Hanny Lightfoot-Klein interviewed 300 Sudanese women and 100 men in the 1980s:

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.

The vulva is opened again (known as defibulation or deinfibulation) for childbirth and restored afterwards (reinfibulation). There is also a process, known in Sudan known as El Adel, in which the vagina is cut again and tightened to mirror the size of the first infibulation. This may be performed before marriage, after childbirth and divorce, and to prepare elderly women for death.

Type IV

The WHO defines Type IV as "[a]ll other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization." The WHO does not classify cosmetic genital procedures or procedures used in sex reassignment surgery as FGM. Type IV includes nicking of the clitoris (known as symbolic circumcision), gishiri cutting, angurya cutting, burning or scarring the genitals, and introducing substances into the vagina to tighten it. Gishiri cutting involves cutting the vagina's anterior (front) wall to enlarge it, and angurya cuts scrape tissue away from around the vagina. Another procedure is hymenotomy, the removal of a hymen regarded as too thick, practised by the Hausa in West Africa. Labia stretching is also categorized as Type IV; in Tanzania and the Congo girls are encouraged to stretch the clitoris and inner labia using sticks.

Complications

FGM has no known health benefits. It has immediate, short-term 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; and whether surgical thread was used instead of agave or acacia thorns. Other factors include 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).

Road sign in Bakau, Gambia, 2005. FGM is not illegal in Gambia, where 76 percent of women and girls have experienced it.

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; few records are kept, complications may not be recognized, and fatalities are rarely reported.

Short-term complications include necrotizing fasciitis, delay in wound healing due to infection, endometritis and hepatitis. 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 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 or 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 centres in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan. In those settings all types of FGM were found to pose an increased risk of death to the baby: 15 percent higher for Type I, 32 percent for Type II and 55 percent for Type III.

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. FGM does not necessarily destroy sexual desire in women; according to 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 in Africa and the Middle East

The practice is mostly found in what political scientist Gerry Mackie describes as an "intriguingly contiguous" zone in Africa – east to west from Somalia to Senegal, and north to south from Egypt to Tanzania.

Information about its prevalence 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).

A 2013 UNICEF report based on 70 of these surveys indicated that FGM is concentrated in 27 African countries, Yemen and Iraqi Kurdistan, and that 125 million women and girls in those countries have been affected. The report grouped the countries according to the prevalence among women aged 15–49:

UNICEF estimate of FGM prevalence in 29 countries
Very high	Moderately high	Moderately low	Low	Very low
Somalia 98%	Gambia 76%	Guinea-Bissau 50%	Central African Republic 24%	Iraq 8%
Guinea 96%	Burkina Faso 76%	Chad 44%	Yemen 23%	Ghana 4%
Djibouti 93%	Ethiopia 74%	Côte d'Ivoire 38%	Tanzania 15%	Togo 4%
Egypt 91%	Mauritania 69%	Kenya 27%	Benin 13%	Niger 2%
Eritrea 89%	Liberia 66%	Nigeria 27%		Cameroon 1%
Mali 89%		Senegal 26%		Uganda 1%
Sierra Leone 88%
Sudan 88%

FGM is concentrated in 27 countries in Africa, as well as Yemen and Iraqi Kurdistan.

Nigeria, with a population of c. 167 million, has the highest number of women and girls who have experienced FGM, around one-quarter of the global number. Around one in five cases is in Egypt.

A country's national prevalence is affected by the practice's concentration among certain ethnicities. In Nigeria, which has a national rate of 27 percent, it is practised by the Yoruba, Hausa, Igbo, Ijaw and Kanuri ethnic groups, but not by the Fula. In Iraq it is found mostly among the Kurds in Erbil, Sulaymaniyah and Kirkuk, giving the country an overall prevalence of eight percent.

Outside the areas in which it is concentrated, FGM has been documented in India, the United Arab Emirates, among the Bedouin in Israel, and reported by anecdote in Colombia, Congo, Oman, Peru and Sri Lanka. It is also practised in Jordan, Saudi Arabia, Indonesia and Malaysia, and by immigrant communities 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 UNICEF 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 without resistance from the child.

Reasons

Overview

Practitioners see the rituals as reinforcing community values and ethnic boundaries, and the procedure as an essential element in raising a girl. The most common reasons for FGM that practitioners have cited in surveys include social acceptance, hygiene, preservation of virginity, marriageability, enhancement of male sexual pleasure, and religion. Infibulation may enhance male pleasure as Gruenbaum writes that men seem to enjoy the effort of penetrating the infibulation. The primary sexual concerns vary between communities. Anika Rahman and Nahid Toubia write that the focus in Egypt, Sudan and Somalia is on curbing premarital sex, while in Kenya and Uganda the aim is to reduce a woman's sexual desire so that her husband can take several wives.

There are also aesthetic factors; according to physicians Miriam Martinelli and Jaume Enric Ollé-Goig, the preference within communities that practise FGM is for women's genitalia to be "flat, rigid and dry." Several myths contribute to FGM's continuance, including that it controls genital discharges, aids conception and birth, that an uncut clitoris will keep growing, and that the clitoris will harm a baby if it comes into contact with the baby's head. A more practical reason for its continuance is that circumcisers rely on the practice for their living.

Mackie compares FGM to footbinding, which was outlawed in China in 1911. Like FGM, footbinding was an ethnic marker carried out on young girls, nearly universal where practised, and tied to ideas about honour, appropriate marriage, health, fertility and aesthetics. It was also supported by the women themselves.

Support from women

Molly Melching of Tostan, celebrating the 10th anniversary of the abandonment of FGM by Malicounda Bambara, the first village in Senegal to do so.

Dahabo Musa, a Somali woman, described infibulation in a 1988 poem as the "three feminine sorrows": the procedure itself, the wedding night when the woman is cut open, then childbirth when she is cut again. Despite the evident suffering, it is women who organize the procedure. Anthropologist Rose Oldfield Hayes wrote in 1975 that educated Sudanese men living in cities who did not want their daughters to be infibulated (preferring clitoridectomy) would find the girls had been sewn up after their grandmothers arranged a visit to relatives.

Fadwa El Guindi argues that FGM is not simply a matter of male control of women, and is neither initiated by nor intended to appeal to men. She writes that across Africa male circumcision is viewed as defeminizing men and FGM as demasculinizing women, and that FGM is chosen by women for women, to reduce sexuality before marriage and to enhance it afterwards.

Women are acutely aware of the low social status of uncut women in communities that practise FGM. Sociologist Elizabeth Heger Boyle writes that several ethnic groups may exclude uncut women from public events; UNICEF reported in 1995 that in Tanzania the Masai will not call an uncut woman "mother" when she has children. Izett and Toubia write that the state of a woman's mutilation becomes part of her gender and social identity. They cite the case of a Somali woman who was advised to remain defibulated after childbirth to cure her gonorrhoea, but who insisted on being reinfibulated, leading to pain so severe she could hardly walk. They argue that she did this out of "her own sense of impurity and shame" at the idea of not being closed.

Only 17.4 percent of 3,210 Sudanese women opposed FGM in a 1982 study, and nearly 59 percent said they preferred excision and infibulation over clitoridectomy. Attitudes have changed somewhat since then. According to UNICEF in 2013, 79 percent of women aged 15–49 in Sudan in 1989–1990 said the practice should continue, compared to 48 percent in 2010. Over 50 percent of women in Mali, Guinea, Sierra Leone, Somalia, Gambia and Egypt support FGM's continuance, but elsewhere in Africa, Iraq and Yemen, most say it should end or are unsure.

Mackie explains the willingness of women to have their daughters and granddaughters cut with the concept of a "belief trap," a belief that "cannot be revised because the costs of testing [it] are too high." The cost of dissent with FGM may be failure to have descendants, because uncut women might not find husbands. Mackie has worked with UNICEF to develop programmes in which villages pledge not to cut girls and to allow their sons to marry uncut girls, which provides the critical mass of support needed for collective abandonment. The American non-profit group Tostan, founded by Molly Melching in 1991, has used this model successfully in Senegal; in 1997 Malicounda Bambara became the first village in Senegal to abandon the practice.

Religion

Further information: Religious views on female genital mutilation

Surveys have shown a widespread belief in practising countries, particularly in Mali, Eritrea, Mauritania, Guinea and Egypt, that FGM is a religious requirement. Gerry Mackie and John LeJeune write that practitioners may not distinguish between religion, tradition and chastity, making it difficult to interpret the data.

Mackie writes that FGM is found "only in or adjacent to" Islamic groups. There is no mention of it in the Quran. 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. Although its origins are pre-Islamic, FGM became associated with Islam because of that religion's focus on female chastity and seclusion. In 2007 the Al-Azhar Supreme Council of Islamic Research in Cairo ruled, according to UNICEF, that FGM had "no basis in core Islamic law or any of its partial provisions."

FGM is also practised by animist groups, particularly in Guinea and Mali, and by Christians. In Niger, for example, 55 percent of Christian women and girls have experienced FGM, compared with two percent of their Muslim counterparts. There is no mention of FGM in the Bible, and Christian missionaries in Africa were among the first to object to it. The only Jewish group known to have practised it are the Beta Israel of Ethiopia; Judaism requires male circumcision, but does not allow FGM.

History

Antiquity

The origins of the practice are unknown. Gerry Mackie has suggested that it began with the Meroite civilization in present-day Sudan. He writes that its east-west, north-south contiguous distribution in Africa intersects in Sudan, and speculates that infibulation originated there with imperial polygyny, before the rise of Islam, to control access to women and increase confidence in paternity.

Spell 1117

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 [unknown substance] of an uncircumcised girl ['m't] and the flakes of skin [šnft] of an uncircumcised bald man.

— Inscription on Egyptian sarcophagus
c. 1991–1786 BCE

Historian Mary Knight writes that there may be a reference to an uncircumcised girl ('m't), written in hieroglyphs in what is known as Spell 1117 of the Coffin Texts (translation right, image below):

The spell was found on the sarcophagus of Sit-hedjhotep, now in the Egyptian Museum, and dates to Egypt's Middle Kingdom, c. 1991–1786 BCE. Paul F. O'Rourke argues that it probably refers to a menstruating woman.

The proposed circumcision of an Egyptian girl, Tathemis, is mentioned on a Greek papyrus from 163 BCE in the British Museum:

Sometime after this, Nephoris [Tathemis's mother] defrauded me, being anxious that it was time for Tathemis to be circumcised, as is the custom among the Egyptians. She asked that I give her 1,300 drachmae ... to clothe her ... and to provide her with a marriage dowry ... if she didn't do each of these or if she did not circumcise Tathemis in the month of Mecheir, year 18 [163 BCE], she would repay me 2,400 drachmae on the spot.

The examination of mummies has shown no evidence of FGM. Citing the Australian pathologist Grafton Elliot Smith (1871–1937), who examined hundreds of mummies in the early 20th century, Knight writes that the genital area may resemble Type III, because during mummification the skin of the outer labia was pulled toward the anus to cover the pudendal cleft, possibly to prevent sexual violation. It was similarly not possible to determine whether Types I or II had been performed, because soft tissues had been removed by the embalmers or had deteriorated.

This is one of the customs most zealously pursued by them [the Egyptians]: to raise every child that is born and to circumcise [peritemnein] the males and excise [ektemnein] the females ...

— Strabo, Geographica.

The Greek geographer Strabo (c. 64 BCE – c. 23 CE) wrote about FGM after visiting Egypt around 25 BCE. The philosopher Philo of Alexandria (c. 20 BCE – 50 CE) also makes reference to the practice: "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." It is mentioned briefly in a work attributed to the Greek physician Galen (129 – c. 200 CE): "When [the clitoris] sticks out to a great extent in their young women, Egyptians consider it appropriate to cut it out."

Another Greek physician, Aëtius of Amida (mid-5th to mid-6th century CE), offered more detail in book 16 of his Sixteen Books on Medicine, citing the physician Philomenes. The procedure was performed in case the clitoris, or nymphê, grew too large or triggered sexual desire when rubbing against clothing. "On this account, it seemed proper to the Egyptians to remove it before it became greatly enlarged," Aëtius wrote, "especially at that time when the girls were about to be married":

The surgery is performed in this way: Have the girl sit on a chair while a muscled young man standing behind her places his arms below the girl's thighs. Have him separate and steady her legs and whole body. Standing in front and taking hold of the clitoris with a broad-mouthed forceps in his left hand, the surgeon stretches it outward, while with the right hand, he cuts it off at the point next to the pincers of the forceps.

It is proper to let a length remain from that cut off, about the size of the membrane that's between the nostrils, so as to take away the excess material only; as I have said, the part to be removed is at that point just above the pincers of the forceps. Because the clitoris is a skinlike structure and stretches out excessively, do not cut off too much, as a urinary fistula may result from cutting such large growths too deeply.

The genital area was then cleaned with a sponge, frankincense powder and wine or cold water, and wrapped in linen bandages dipped in vinegar until the seventh day, when calamine, rose petals, date pits or a "genital powder made from baked clay" might be spread on the wound.

Whatever the practice's origins, infibulation became linked to slavery. Mackie cites the Portuguese missionary João dos Santos (d. 1622), who in 1609 wrote of a group inland from 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." The English explorer William Browne (1768–1813) wrote in 1799 that the Egyptians practised excision, and that slaves in that country were infibulated to prevent pregnancy. Thus, Mackie argues, 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 removed the clitoris to treat insanity and masturbation. British doctor Robert Thomas suggested clitoridectomy as a cure for nymphomania in 1813. One of the first reported clitoridectomies in the West was performed in 1822 in Berlin by Karl Ferdinand von Graefe (1787–1840), 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 masturbation, or "unnatural irritation" of the clitoris, caused epilepsy, hysteria, mania and idiocy, 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 performed several clitoridectomies between 1859 and 1866. When he published his views in On the Curability of Certain Forms of Insanity, Epilepsy, Catalepsy, and Hysteria in Females (1866), doctors in London accused him of quackery and expelled him from the Obstetrical Society.

In the United States J. Marion Sims (1813–1883) 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. G. J. Barker-Benfield writes that clitoridectomy continued in the US until at least 1904 and perhaps into the 1920s. According to a 1985 paper in the Obstetrical & Gynecological Survey, it was performed in the US into the 1960s to treat hysteria, erotomania and lesbianism.

Opposition

Colonial opposition in Kenya

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

Muthirigu

Little knives in their sheaths
That they may fight with the church,
The time has come.
Elders (of the church)
When Kenyatta comes
You will be given women's clothes
And you will have to cook him his food.

— from the Muthirigu (1929), Kikuyu dance-songs protesting church opposition to FGM

Protestant missionaries in British East Africa (present-day Kenya), began campaigning against FGM in the early 20th century when Dr. John Arthur (1881–1952) joined the Church of Scotland Mission (CSM) in Kikuyu. The practice was known by the Kikuyu, the country's main ethnic group, as irua for both girls and boys, and involved excision (Type II) for girls and removal of the foreskin for boys. It was an important ethnic marker, and unexcised Kikuyu women, known as irugu, were outcasts.

Jomo Kenyatta (c. 1894–1978), general secretary of the Kikuyu Central Association and Kenya's first prime minister from 1963, wrote in 1938 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 proper Kikuyu man or woman would marry or have sexual relations with someone who was not circumcised. A woman's responsibilities toward the tribe began with her initiation; her age and place within tribal history was traced to that day, and the group of girls with whom she was cut was named according to current events. Kenyatta gave as an example a famine occurring around the time of a ceremony; that group of initiates would thereafter be known as "famine," an oral tradition that allowed the Kikuyu to track people and events going back hundreds of years.

Missionary Hulda Stumpf was murdered in Kikuyu in 1930 after opposing FGM.

From 1925, beginning with the CSM mission, several missionary churches declared that FGM was prohibited for African Christians. The CSM announced that Africans practising it would be excommunicated, resulting in hundreds leaving or being expelled. The stand-off turned FGM into a focal point of the Kenyan independence movement; the 1929–1931 period is known in the country's historiography as the female circumcision controversy.

In 1929 the Kenya Missionary Council began referring to FGM as the "sexual mutilation of women," rather than circumcision, and a person's stance toward the practice became a test of loyalty, either to the Christian churches or the Kikuyu Central Association. Hulda Stumpf (1867–1930), an American missionary with the Africa Inland Mission who opposed FGM in the girls' school she helped to run, was murdered in 1930 after apparently being circumcised by her attacker.

In 1956 the council of male elders (the Njuri Nchecke) in Meru announced a ban on FGM. Over the next three years, as a symbol of defiance, thousands of girls cut each other's genitals with razor blades. The movement came to be known in Meru as Ngaitana ("I will circumcise myself"), because to avoid naming their friends the girls said they had cut themselves. Historian Lynn Thomas describes the episode as significant in the history of FGM because it made clear that its victims were also its perpetrators.

Growth of opposition

The first known non-colonial campaign against FGM began in Egypt in the 1920s, when the Egyptian Doctors' Society called for a ban. A parallel campaign began in Sudan in the 1920s and 1930s. Sudan, then under Anglo-Egyptian control, banned infibulation in 1946, but the law was unpopular and barely enforced. The Egyptian government banned infibulation in state-run hospitals in 1959, but allowed partial clitoridectomy if parents requested it. The UN asked the WHO to investigate FGM that year, but the latter responded that it was not a medical issue.

Feminists took up the issue throughout the 1970s. Egyptian physician Nawal El Saadawi's book, Women and Sex (1972), criticized FGM, was banned in Egypt, and saw El Saadawi lose her job as director general of public health. She followed up with a chapter, "The Circumcision of Girls," in The Hidden Face of Eve: Women in the Arab World (1980), which described her own clitoridectomy when she was six years old:

Egyptian physician Nawal El Saadawi was one of the first African feminists to criticize FGM.

I did not know what they had cut off from my body, and I did not try to find out. I just wept, and called out to my mother for help. But the worst shock of all was when I looked around and found her standing by my side. Yes, it was her, I could not be mistaken, in flesh and blood, right in the midst of these strangers, talking to them and smiling at them, as though they had not participated in slaughtering her daughter just a few moments ago.

In 1975 the American social scientist Rose Oldfield Hayes became the first female academic to publish a detailed account of FGM, aided by her ability to discuss the issues directly with women in Sudan. Her article in American Ethnologist called it "female genital mutilation," and brought it to wider academic attention.

Fran Hosken's 1979 report was the first to estimate numbers.

Four years later Austrian-American feminist Fran Hosken (1920–2006) published The Hosken Report: Genital and Sexual Mutilation of Females (1979), the first to estimate the global number of women cut; she wrote that 110,529,000 women in 20 African countries had experienced it. Describing FGM as a "training ground for male violence," she accused female practitioners of "participating in the destruction of their own kind." The language caused a rift between Western and African feminists; African women boycotted a session featuring Hosken during the UN's Mid-Decade Conference on Women in Copenhagen in July 1980.

The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children called for an end to the practice in 1984, as did the UN's World Conference on Human Rights in 1993. Throughout the 1990s and 2000s African governments banned or restricted it. In 2003 the United Nations began sponsoring an International Day of Zero Tolerance to Female Genital Mutilation every 6 February, and in July that year the African Union ratified the Maputo Protocol, promising to prohibit FGM.

In December 2012 the UN General Assembly passed Resolution 67/146, calling for intensified efforts to end FGM. By 2013 laws had been passed in 22 of the 27 African countries in which it is concentrated, though several fell short of a ban. Egypt, where the practice may have originated, finally outlawed it in 2008 after two incidents attracted international attention: in 1994 CNN broadcast images of a child undergoing FGM in a barber's shop in Cairo, a child died during an FGM procedure in 2007. The death prompted the Al-Azhar Supreme Council of Islamic Research, the country's highest religious authority, to rule that FGM had no basis in Islamic law, and the government outlawed it the following year. The first criminal charges under the new law were laid in 2014.

Law in non-practising countries

Further information: Prevalence of female genital mutilation by country and Female genital mutilation in the UK

As a result of immigration, the practice spread to Australia, Europe, North America and Scandinavia. 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 clear that FGM was covered by existing legislation. It is banned or restricted in Australia, New Zealand, the European Union, the United States and Canada.

Efua Dorkenoo, author of Cutting the Rose (1994) and founder of FORWARD, received an OBE for her work against FGM in the UK.

Canada recognized FGM as a form of persecution in July 1994, when it granted refugee status to Khadra Hassan Farah, who had fled Somalia to avoid her daughter being cut. FGM is outlawed by section 268 of the Criminal Code of Canada unless "the person is at least eighteen years of age and there is no resulting bodily harm." As of May 2012 there had been no prosecutions.

There have been over 100 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. Up to 30,000 women there are thought to have experienced FGM. Colette Gallard, a family-planning counsellor, writes that when FGM was first encountered in France, the 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. The first civil suit was in 1982 and the first criminal prosecution in 1993. In 1999 a woman was sentenced to eight years' imprisonment for having performed FGM on 48 girls.

Nearly 66,000 women in England and Wales were living with FGM in 2001, according to the only national estimate. It is an offence in the UK to perform FGM on children or adults. The Prohibition of Female Circumcision Act 1985 outlawed it, and the Female Genital Mutilation Act 2003 and the Prohibition of Female Genital Mutilation (Scotland) Act 2005 made it an offence to arrange it outside the country for British citizens or permanent residents. The first charges were brought in March 2014, against a physician and another man, after the physician performed 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 in 1990 had undergone FGM or were at risk. A Nigerian woman successfully contested deportation in March 1994 on the grounds that her daughters might be cut, and in 1996 19-year-old Fauziya Kasinga from Togo became the first to be granted asylum to escape FGM. In September 1996 the Illegal Immigration Reform and Immigrant Responsibility Act made it illegal to perform FGM on minors for non-medical reasons, and in January 2013 the Transport for Female Genital Mutilation Act prohibited knowingly transporting a minor out of the country for the purpose of FGM. The first FGM conviction was in 2006, when Khalid Adem, who had emigrated from Ethiopia, was sentenced to ten years after severing his two-year-old daughter's clitoris with a pair of scissors.

Criticism of opposition

Tolerance versus human rights

Anthropologist Eric Silverman writes that FGM is one of the "central moral topics of contemporary anthropology." Anthropologists have accused FGM eradicationists of cultural colonialism; they, in turn, have been criticized for their cultural and moral relativism toward FGM, and a failure to defend the idea of universal human rights. The debate highlights a tension between anthropology and feminism, with the former's focus on tolerance and the latter's on rights for all women, raising questions about the extent to which an embrace of multiculturalism implies that different standards ought to apply to African women. The French Association of Anthropologists accused feminists, in 1981, of reviving "the moralistic arrogance of yesterday's colonialism."

photograph

Social scientist Stanlie James accused Alice Walker (pictured), whose novels Possessing the Secret of Joy (1992) and Warrior Marks (1993) criticize FGM, of trying to save African women from themselves.

Anthropologists challenging the opposition to FGM include Richard Shweder, Janice Boddy, Carla Obermeyer, Ellen Gruenbaum and Fuambai Ahmadu, who was cut as an adult during a Sande society initiation in Sierra Leone. Shweder argues against the idea of universal human rights, but maintains that if a rights perspective is adopted, it must take other rights into account, such as the right of African women to self-determination and freedom of religion.

Ugandan law professor Sylvia Tamale writes that early Western opposition to FGM stemmed from a Judeo-Christian judgment that African sexual culture, including not only FGM but also dry sex, polygyny and levirate marriage, was primitive and required correction. She cautions that, while African feminists "do not condone the negative aspects of the practice, they take strong exception to the imperialist, racist and dehumanising infantilization of African women," inherent in much of the opposition. A common trope in the literature about FGM, according to Christine J. Walley, is to present African women as "mentally castrated," participating in their own oppression and destruction as a result of false consciousness. Fran Hosken and the American feminist Mary Daly both promoted that position in the 1970s.

As an example of the disrespect, historian Chima Korieh cites the publication by 12 American newspapers of the FGM ceremony of a 16-year-old girl in Kenya in 1996. The photographs won the Pulitzer Prize for Feature Photography, but according to Korieh the girl had not given permission for the images to be published or even taken.

One of the areas of dispute is whether the medical evidence supports that FGM is invariably harmful. Shweder argues that it does not, citing reviews of the medical literature by epidemiologist Carla Obermeyer, who suggested in 1999 and 2003 that serious complications are the exception. Gerry Mackie disputed Obermeyer's findings. 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

Several authors 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 were "driving the advance of female genital mutilation" by encouraging women to see natural variations as defects. Anthropologist Fadwa El Guindi compares FGM to breast enhancement, in which the maternal function of the breast becomes secondary to men's sexual pleasure; indeed, she argues, breast enhancement could be called breast mutilation, particularly when the nipples lose sensation because of implants. Benoîte Groult made a similar point in 1975, citing FGM and cosmetic surgery as sexist and patriarchal. Carla Obermeyer argues that FGM may be conducive to women's well-being within their communities in the same way that breast implants, rhinoplasty and male circumcision may help people elsewhere.

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

The WHO does not include cosmetic procedures such as labiaplasty, vaginoplasty and clitoral hood reduction as examples of FGM; some elective practices do fall within its categories, but its broad definition aims to avoid loopholes. Some of the legislation banning FGM would seem to cover cosmetic genital alteration too. 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 consent. Gynaecologist Birgitta Essén and anthropologist Sara Johnsdotter argue that it seems the law distinguishes between Western and African genitals, and deems only African women (such as those seeking reinfibulation after childbirth) unfit to make their own decisions.

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

Several commentators argue that children's rights are violated with the genital alteration of intersex children, who are born with anomalies that physicians choose to correct. 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."

Further reading

Resources

• Desert Flower Foundation, first dedicated FGM clinic in Europe.
• FORWARD, London, charity specializing in FGM (FORWARD's list of UK clinics offering specialist FGM services).
• National Society for the Prevention of Cruelty to Children, UK, 24-hour national helpline for children at risk of FGM: 0800 028 3550
• Tahirih Justice Center, provides medical/legal services in the US to immigrant women fleeing gender-based persecution.
• "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, articles

• Bryk, Felix. Circumcision in Man and Woman: Its History, Psychology, and Ethnology, The Minerva Group, Inc., 2001, first published 1934.
• CNN. Report on FGM in Egypt, February 2009.
• Sembène, Ousmane. Moolaadé, 2004, film about abandoning FGM.
• Sinclair, Stephanie. "Inside a Female-Circumcision Ceremony", The New York Times magazine, April 2006, slideshow of images from Indonesia (article).
• The Guardian. FGM archive; "The facts about female genital mutilation – interactive", interactive display with facts and figures from UNICEF, 22 July 2013.
• Yoder, P. Stanley; Noureddine, Abderrahim; Arlinda, Zhuzhuni. "Female Genital Cutting in the Demographic and Health Surveys: A Critical and Comparative Analysis", DHS Comparative Reports No. 7, 2004.

Personal stories

• Ali, Ayaan Hirsi. Infidel: My Life, Simon & Schuster, 2007.
• Dirie, Waris. Desert Flower, Harper Perennial, 1999.
• Dirie, Waris. Desert Dawn, Little, Brown, 2003.
• Dirie, Waris. Desert Children, Virago, 2007.
• 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.