Genital Mutilation

The different types of mutilation
Female genital mutilation (FGM) is the term used to refer to the removal of part, or all, of the female genitalia. The most severe form is infibulation, also known as pharaonic circumcision. An estimated 15% of all mutilations in Africa are infibulations. The procedure consists of clitoridectomy (where all, or part of, the clitoris is removed), excision (removal of all, or part of, the labia minora), and cutting of the labia majora to create raw surfaces, which are then stitched or held together in order to form a cover over the vagina when they heal. A small hole is left to allow urine and menstrual blood to escape. In some less conventional forms of infibulation, less tissue is removed and a larger opening is left.

SECTION:
What is female genital mutilation?
Why and how Amnesty International took up the issue of FGM

A role for Amnesty International

A human rights issue

International human rights standards

FGM and asylum

United Nations Initiatives

Strategies for change

Information by country

Contact organsations and advocacy groups

Selected bibliography

The vast majority (85%) of genital mutilations performed in Africa consist of clitoridectomy or excision. The least radical procedure consists of the removal of the clitoral hood.

In some traditions a ceremony is held, but no mutilation of the genitals occurs. The ritual may include holding a knife next to the genitals, pricking the clitoris, cutting some pubic hair, or light scarification in the genital or upper thigh area.
The procedures followed
The type of mutilation practised, the age at which it is carried out, and the way in which it is done varies according to a variety of factors, including the woman or girl's ethnic group, what country they are living in, whether in a rural or urban area and their socio-economic provenance.

The procedure is carried out at a variety of ages, ranging from shortly after birth to some time during the first pregnancy, but most commonly occurs between the ages of four and eight. According to the World Health Organization, the average age is falling. This indicates that the practice is decreasingly associated with initiation into adulthood, and this is believed to be particularly the case in urban areas.

Some girls undergo genital mutilation alone, but mutilation is more often undergone as a group of, for example, sisters, other close female relatives or neighbours. Where FGM is carried out as part of an initiation ceremony, as is the case in societies in eastern, central and western Africa, it is more likely to be carried out on all the girls in the community who belong to a particular age group.

The procedure may be carried out in the girl's home, or the home of a relative or neighbour, in a health centre, or, especially if associated with initiation, at a specially designated site, such as a particular tree or river. The person performing the mutilation may be an older woman, a traditional midwife or healer, a barber, or a qualified midwife or doctor.

Girls undergoing the procedure have varying degrees of knowledge about what will happen to them. Sometimes the event is associated with festivities and gifts. Girls are exhorted to be brave. Where the mutilation is part of an initiation rite, the festivities may be major events for the community. Usually only women are allowed to be present.

Sometimes a trained midwife will be available to give a local anaesthetic. In some cultures, girls will be told to sit beforehand in cold water, to numb the area and reduce the likelihood of bleeding. More commonly, however, no steps are taken to reduce the pain. The girl is immobilized, held, usually by older women, with her legs open. Mutilation may be carried out using broken glass, a tin lid, scissors, a razor blade or some other cutting instrument. When infibulation takes place, thorns or stitches may be used to hold the two sides of the labia majora together, and the legs may be bound together for up to 40 days. Antiseptic powder may be applied, or, more usually, pastes - containing herbs, milk, eggs, ashes or dung - which are believed to facilitate healing. The girl may be taken to a specially designated place to recover where, if the mutilation has been carried out as part of an initiation ceremony, traditional teaching is imparted. For the very rich, the mutilation procedure may be performed by a qualified doctor in hospital under local or general anaesthetic.

Geographical distribution of female genital mutilation
An estimated 135 million of the world's girls and women have undergone genital mutilation, and two million girls a year are at risk of mutilation - approximately 6,000 per day. It is practised extensively in Africa and is common in some countries in the Middle East. It also occurs, mainly among immigrant communities, in parts of Asia and the Pacific, North and Latin America and Europe.

FGM is reportedly practised in more than 28 African countries (see FGM in Africa: Information by Country (ACT 77/07/97)). There are no figures to indicate how common FGM is in Asia. It has been reported among Muslim populations in Indonesia, Sri Lanka and Malaysia, although very little is known about the practice in these countries. In India, a small Muslim sect, the Daudi Bohra, practise clitoridectomy.

In the Middle East, FGM is practised in Egypt, Oman, Yemen and the United Arab Emirates.

There have been reports of FGM among certain indigenous groups in central and south America, but little information is available.

In industrialized countries, genital mutilation occurs predominantly among immigrants from countries where mutilation is practised. It has been reported in Australia, Canada, Denmark, France, Italy, the Netherlands, Sweden, the UK and USA. Girls or girl infants living in industrialized countries are sometimes operated on illegally by doctors from their own community who are resident there. More frequently, traditional practitioners are brought into the country or girls are sent abroad to be mutilated. No figures are available on how common the practise is among the populations of industrialized countries.

The physical and psychological effects of female genital mutilation

Physical effects
The effects of genital mutilation can lead to death. At the time the mutilation is carried out, pain, shock, haemorrhage and damage to the organs surrounding the clitoris and labia can occur. Afterwards urine may be retained and serious infection develop. Use of the same instrument on several girls without sterilization can cause the spread of HIV.

More commonly, the chronic infections, intermittent bleeding, abscesses and small benign tumours of the nerve which can result from clitoridectomy and excision cause discomfort and extreme pain.

Infibulation can have even more serious long-term effects: chronic urinary tract infections, stones in the bladder and urethra, kidney damage, reproductive tract infections resulting from obstructed menstrual flow, pelvic infections, infertility, excessive scar tissue, keloids (raised, irregularly shaped, progressively enlarging scars) and dermoid cysts.

First sexual intercourse can only take place after gradual and painful dilation of the opening left after mutilation. In some cases, cutting is necessary before intercourse can take place. In one study carried out in Sudan, 15% of women interviewed reported that cutting was necessary before penetration could be achieved.1 Some new wives are seriously damaged by unskilful cutting carried out by their husbands. A possible additional problem resulting from all types of female genital mutilation is that lasting damage to the genital area can increase the risk of HIV transmission during intercourse.

During childbirth, existing scar tissue on excised women may tear. Infibulated women, whose genitals have been tightly closed, have to be cut to allow the baby to emerge. If no attendant is present to do this, perineal tears or obstructed labour can occur. After giving birth, women are often reinfibulated to make them "tight" for their husbands. The constant cutting and restitching of a women's genitals with each birth can result in tough scar tissue in the genital area.

The secrecy surrounding FGM, and the protection of those who carry it out, make collecting data about complications resulting from mutilation difficult. When problems do occur these are rarely attributed to the person who performed the mutilation. They are more likely to be blamed on the girl's alleged "promiscuity" or the fact that sacrifices or rituals were not carried out properly by the parents. Most information is collected retrospectively, often a long time after the event. This means that one has to rely on the accuracy of the woman's memory, her own assessment of the severity of any resulting complications, and her perception of whether any health problems were associated with mutilation.

Some data on the short and long-term medical effects of FGM, including those associated with pregnancy, have been collected in hospital or clinic-based studies, and this has been useful in acquiring a knowledge of the range of health problems that can result. However, the incidence of these problems, and of deaths as a result of mutilation, cannot be reliably estimated. Supporters of the practice claim that major complications and problems are rare, while opponents of the practice claim that they are frequent.

Effects on sexuality
Genital mutilation can make first intercourse an ordeal for women. It can be extremely painful, and even dangerous, if the woman has to be cut open; for some women, intercourse remains painful. Even where this is not the case, the importance of the clitoris in experiencing sexual pleasure and orgasm suggests that mutilation involving partial or complete clitoridectomy would adversely affect sexual fulfilment. Clinical considerations and the majority of studies on women's enjoyment of sex suggest that genital mutilation does impair a women's enjoyment. However, one study found that 90% of the infibulated women interviewed reported experiencing orgasm.2 The mechanisms involved in sexual enjoyment and orgasm are still not fully understood, but it is thought that compensatory processes, some of them psychological, may mitigate some of the effects of removal of the clitoris and other sensitive parts of the genitals.

Psychological effects
The psychological effects of FGM are more difficult to investigate scientifically than the physical ones. A small number of clinical cases of psychological illness related to genital mutilation have been reported.3 Despite the lack of scientific evidence, personal accounts of mutilation reveal feelings of anxiety, terror, humiliation and betrayal, all of which would be likely to have long-term negative effects. Some experts suggest that the shock and trauma of the operation may contribute to the behaviour described as "calmer" and "docile", considered positive in societies that practise female genital mutilation.

Festivities, presents and special attention at the time of mutilation may mitigate some of the trauma experienced, but the most important psychological effect on a woman who has survived is the feeling that she is acceptable to her society, having upheld the traditions of her culture and made herself eligible for marriage, often the only role available to her. It is possible that a woman who did not undergo genital mutilation could suffer psychological problems as a result of rejection by the society. Where the FGM-practising community is in a minority, women are thought to be particularly vulnerable to psychological problems, caught as they are between the social norms of their own community and those of the majority culture.

Why FGM is practised

Cultural identity
Custom and tradition are by far the most frequently cited reasons for FGM. Along with other physical or behavioural characteristics, FGM defines who is in the group. This is most obvious where mutilation is carried out as part of the initiation into adulthood.

Jomo Kenyatta, the late President of Kenya, argued that FGM was inherent in the initiation which is in itself an essential part of being Kikuyu, to such an extent that "abolition... will destroy the tribal system".5 A study in Sierra Leone reported a similar feeling about the social and political cohesion promoted by the Bundo and Sande secret societies, who carry out initiation mutilations and teaching.

Many people in FGM-practising societies, especially traditional rural communities, regard FGM as so normal that they cannot imagine a woman who has not undergone mutilation. Others are quoted as saying that only outsiders or foreigners are not genitally mutilated. A girl cannot be considered an adult in a FGM-practising society unless she has undergone FGM.

"Of course I shall have them circumcised exactly as their parents, grandparents and sisters were circumcised. This is our custom."
An Egyptian woman, talking about her young daughters 4

Gender identity
FGM is often deemed necessary in order for a girl to be considered a complete woman, and the practice marks the divergence of the sexes in terms of their future roles in life and marriage.

The removal of the clitoris and labia ' viewed by some as the "male parts" of a woman's body ' is thought to enhance the girl's femininity, often synonymous with docility and obedience.

It is possible that the trauma of mutilation may have this effect on a girl's personality. If mutilation is part of an initiation rite, then it is accompanied by explicit teaching about the woman's role in her society. "We are circumcised and insist on circumcising our daughters so that there is no mixing between male and female... An uncircumcised woman is put to shame by her husband, who calls her 'you with the clitoris'. People say she is like a man. Her organ would prick the man..."
An Egyptian woman 6
Control of women's sexuality and reproductive functions
In many societies, an important reason given for FGM is the belief that it reduces a woman's desire for sex, therefore reducing the chance of sex outside marriage. The ability of unmutilated women to be faithful through their own choice is doubted. In many FGM-practising societies, it is extremely difficult, if not impossible, for a woman to marry if she has not undergone mutilation. In the case of infibulation, a woman is "sewn up" and "opened" only for her husband. Societies that practise infibulation are strongly patriarchal. Preventing women from indulging in "illegitimate" sex, and protecting them from unwilling sexual relations, are vital because the honour of the whole family is seen to be dependent on it. Infibulation does not, however, provide a guarantee against "illegitimate" sex, as a woman can be "opened" and "closed" again.

In some cultures, enhancement of the man's sexual pleasure is a reason cited for mutilation. Anecdotal accounts, however, suggest that men prefer unmutilated women as sexual partners. "Circumcision makes women clean, promotes virginity and chastity and guards young girls from sexual frustration by deadening their sexual appetite."
Mrs Njeri, a defender of female genital mutilation in Kenya7
Beliefs about hygiene, aesthetics and health
Cleanliness and hygiene feature consistently as justifications for FGM. Popular terms for mutilation are synonymous with purification (tahara in Egypt, tahur in Sudan), or cleansing (sili-ji among the Bambarra, an ethnic group in Mali). In some FGM-practising societies, unmutilated women are regarded as unclean and are not allowed to handle food and water.

Clitoridectomy and Infibulation on African Infants

"She loses only a little piece of the clitoris, just the part that protrudes. The girl does not miss it. She can still feel, after all. There is hardly any pain. Women's pain thresholds are so much higher than men's." "It's only a little piece of skin. The baby does not feel any pain because his nervous system is not developed yet."

"The parts that are cut away are disgusting and hideous to look at. It is done for the beauty of the suture." "An uncircumcised penis is a real turn-off. Its disgusting. It looks like the penis of an animal."

"Female circumcision protects the health of a woman. Infibulation prevents the uterus from falling out [uterine prolapse]. It keeps her smelling so sweet that her husband will be pleased. If it is not done, she will stink and get worms in her vagina." "An uncircumcised penis causes urinary infections and penile cancer. It generates smegma and smegma stinks. A circumcised penis is more hygienic and oral sex with an uncircumcised penis is disgusting to women."
"An uncircumcised vulva is unclean and only the lowest prostitute would leave her daughter uncircumcised. No man would dream of marrying an unclean woman. He would be laughed at by everyone." "An uncircumcised penis is dirty and only the lowest class of people with no concept of hygiene leave their boys uncircumcised."

"Leaving a girl uncircumcised endangers both her husband and her baby. If the baby's head touches the uncut clitoris during birth, the baby will be born hydrocephalic [excess cranial fluid]. The milk of the mother will become poisonous. If a man's penis touches a woman's clitoris he will become impotent." "Men have an obligation to their wives to give up their foreskin. An uncircumcised penis will cause cervical cancer in women. It also spreads disease."
"A circumcised woman is sexually more pleasing to her husband. The tighter she is sewn, the more pleasure he has." "Circumcised men make better lovers because they have no more staying power than uncircumcised men."

"All the women in the world are circumcised. It is something that must be done. If there is pain, then that is part of a woman's lot in life." "Men in all the 'civilized' world are circumcised."
"Doctors do it, so it must be a good thing." "Doctors do it, so it must be a good thing."
Sudanese grandmother: "In some countries they only cut out the clitoris, but here we do it properly. We scrape our girls clean. If it is properly done, nothing is left, other than a scar. Everything has to be cut away." My own father, a physician, speaking of ritual circumcision inflicted upon my son: "It is a good thing that I was here to preside. He had quite a long foreskin. I made sure that we gave him a good tight circumcision."

35 year old Sudanese woman: "Yes, I have suffered from chronic pelvic infections and terrible pain for years now. You say that all if this is the result of my circumcision? But I was circumcised over 30 years ago! How can something that was done for me when I was four years old have anything to do with my health now?" 35 years old American male: "I have lost nearly all interest in sex. You might say that I'm becoming impotent. I don't seem to have much sensation in my penis anymore, and it is becoming more and more difficult for me to reach orgasm. You say that this is the result of my circumcision? That doesn't make any sense. I was circumcised 35 years ago, when I was a little boy. How can that affect me in any way now?"