Female genital mutilation (FGM) is defined by the World Health Organization (WHO) as all procedures which involve partial or total removal of the external female genitalia and/or injury to the female genital organs, whether for cultural or any other non-therapeutic reasons.
It's also known as "female circumcision" or "cutting", and by other terms such as sunna, gudniin, halalays, tahur, megrez and khitan, among others.
FGM is usually carried out on young girls between infancy and the age of 15, most commonly before puberty starts.
FGM is a practice whose origin and significance is shrouded in secrecy, uncertainty, and confusion. The origin of FGM is fraught with controversy either as an initiation ceremony of young girls into womanhood or to ensure virginity and curb promiscuity, or to protect female modesty and chastity. The ritual has been so widespread that it could not have risen from a single origin.
FGM is an unhealthy traditional practice inflicted on girls and women worldwide. FGM is widely recognized as a violation of human rights, which is deeply rooted in cultural beliefs and perceptions over decades and generations with no easy task for change.
FGM usually happens to girls whose mothers, grandmothers or extended female family members have had FGM themselves or if their father comes from a community where it's carried out.
In Nigeria, subjection of girls and women to obscure traditional practices is legendary. Nigeria, due to its large population, has the highest absolute number of female genital mutilation (FGM) worldwide, accounting for about one-quarter of the estimated 115–130 million circumcised women in the world.
Globally, evidence abound that the prevalence of FGM is declining. The ongoing drive to eradicate FGM is tackled by World Health Organization (WHO), United Nations International Children Emergency Fund (UNICEF), Federation of International Obstetrics and Gynaecology (FIGO), African Union (AU), the Economic Commission for Africa (ECA), and many women organizations.
Where is FGM practiced?
The practice can be found in communities around the world.
In Africa, FGM is known to be practiced among certain communities in 29 countries: Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Cote d'Ivoire, Democratic Republic of Congo, Djibouti, Egypt, Eritrea, Ethiopia, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, Somalia, Sudan, Tanzania, Togo, Uganda and Zambia.
Certain ethnic groups in Asian countries practice FGM, including in communities in India, Indonesia, Malaysia, Pakistan and Sri Lanka.
In the Middle East, the practice occurs in Oman, the United Arab Emirates and Yemen, as well as in Iraq, Iran, the State of Palestine and Israel.
In Eastern Europe, recent info shows that certain communities are practicing FGM in Georgia and the Russian Federation.
In South America, certain communities are known to practice FGM in Columbia, Ecuador, Panama and Peru.
And in many western countries, including Australia, Canada, New Zealand, the United States, the United Kingdom and various European countries, FGM is practiced among diaspora populations from areas where the practice is common.
FGM and Women's Rights
FGM is recognized worldwide as a fundamental violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes and constitutes an extreme form of discrimination against women. It involves violation of rights of the children and violation of a person's right to health, security, and physical integrity, the right to be free from torture and cruel, inhuman, or degrading treatment, and the right to life when the procedure results in death. Furthermore, girls usually undergo the practice without their informed consent, depriving them of the opportunity to make independent decision about their bodies.
Forms of FGM
There are four main types of FGM:
Type I (clitoridectomy) – removing part or all of the clitoris.
Type II (excision) – removing part or all of the clitoris and the inner labia (lips that surround the vagina), with or without removal of the labia majora (larger outer lips).
Type III: The most severe form, it is also known as infibulation or pharaonic type. The procedure consists of narrowing the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or labia majora, with or without removal of the clitoris. The appositioning of the wound edges consists of stitching or holding the cut areas together for a certain period of time (for example, girls’ legs are bound together), to create the covering seal. A small opening is left for urine and menstrual blood to escape. An infibulation must be opened either through penetrative sexual intercourse or surgery.
Other harmful procedures to the female genitals, including pricking, piercing, cutting, scraping or burning the area.
FGM is often performed by traditional circumcisers or cutters who do not have any medical training. However, in some countries it may be done by a medical professional.
Anaesthetics and antiseptics aren't generally used, and FGM is often carried out using knives, scissors, scalpels, pieces of glass or razor blades.
FGM often happens against a girl's will, without her consent and girls may have to be forcibly restrained.
Which types are most common?
Types I and II are the most common, but there is variation among countries. Type III – infibulation – is experienced by about 10 per cent of all affected women and is most likely to occur in Somalia, northern Sudan and Djibouti.
Health Risks of Female Genital Mutilation (FGM)
There are no health benefits to FGM and it can cause serious harm.
Considering the clumsy and un-hygienic conditions under which female genital mutilation is usually performed, complications are frequent and numerous and can be classified in the order in which they are likely to occur.
Short term complications
Haemorrhage is one of the most common complications of FGM, as excision of the clitoris involves cutting across the high pressure clitoral artery and attempts to stop bleeding may not be effective. Acute extensive bleeding can lead to haemorrhagic shock or even sudden death in the case of cataclysmic haemorrhage.
Shock may occur because of blood loss and the severe pain and trauma of the procedure. Both haemorrhagic and neurogenic shock can be fatal.
The majority of mutilation procedures are performed without anaesthetics and cause the girl severe pain. Even if a local anaesthetic is used, multiple insertions of the needle are often required.
Urinary Retention is very common and may last for hours or days. It is commonly due to pain, tissue swelling, inflammation, injury to the urethra, and fear of passing urine on the raw wound.
Injury to adjacent tissue
Injury to the urethra, vagina, perineum and rectum can result from the use of crude instruments, poor light, careless techniques, or from the struggles of the girl.
Infection commonly occurs for a number of reasons; unhygienic conditions, the use of unsterilized instruments, applications of traditional herbs or ashes to the wound, contamination of the wound with urine and/or faeces, or binding of the legs following infibulation which prevents wound drainage. Septicaemia and tetanus may also develop.
Fracture or dislocation
Fracture of the clavicle, femur, humerus or hip joint can occur if heavy pressure is applied to a struggling girl during the procedure - as often occurs when several adults hold her down.
Failure to heal
Wounds may fail to heal quickly because of infection, irritation from urine, underlying anaemia or malnutrition.
This can be caused by infections, including tetanus and haemorrhage that can lead to shock.
Long term complications
Difficulties with micturition
Difficulties can occur due to damage to the urethral opening, obstruction of the urinary opening, or scarring of the meatus - and can lead to chronic incontinence or difficulty passing urine. For many infibulated girls, passing urine can take up to 20 minutes when they are still virgins.
Recurrent urinary tract infections (UTIS)
Partial occlusion of the vagina and urethra means the normal flow of urine is deflected and the perineum remains constantly wet and susceptible to bacterial growth. Retrograde UTI's therefore commonly occur, affecting the bladder, uterus and kidneys. Damage to the lower urinary tract during the procedure can also result in urinary tract infections.
Chronic pelvic infections
Partial occlusion of the vagina and urethra increases the likelihood of infection and ascending pelvic infections are common. The infections are often painful and may be accompanied by a noxious discharge spreading to the uterus, fallopian tubes and ovaries - and frequently become chronic.
Infertility can occur due to chronic pelvic infections causing irreparable damage to the reproductive organs.
Vulval abscesses develop due to deep infection resulting from faulty healing or an embedded stitch causing the formation of an abscess.
Neurinoma can develop when the dorsal nerve of the clitoris is cut or trapped in a stitch or in scar tissue. The surrounding area becomes hypersensitive and unbearably painful.
Keloid scars result from slow and incomplete healing of the wound and the production of excess scar tissue. The scars may obstruct the vaginal opening and be so extensive that they prevent penile penetration.
Dermoid cysts result from inclusion of the epithelium during healing, leading to swelling or pockets producing secretion. The cysts vary in size, are extremely painful and can prevent sexual intercourse.
Calculus formation develop due to menstrual debris or urinary deposits in the vagina or in the space behind the bridge of the scar tissue.
Vesico-vaginal or recto-vaginal fistulae can form as a result of injury during circumcision, de-infibulation, re-infibulation, sexual intercourse, or obstructed labour. Urinary and faecal incontinence may be lifelong with severe social consequences.
Difficulties with menstruation
Partial or total occlusion of the vaginal opening commonly results in dysmenorrhoea or amenorrhea. Haematocolpos occasionally occurs from the retention of menstrual blood due to the almost complete coalescence of the labia.
Increased risk of HIV transmission
There is an increased risk of HIV transmission due to the use of the same unsterile instruments in-group circumcisions, repeated cutting and stitching during labour, and the higher incidence of lacerations and abrasions during intercourse.
Many women who have undergone FGM experience various forms and degrees of sexual aberrations. These may include fear associated with initial sexual intercourse, pain associated with sexual intercourse, difficulty or inability to have sexual intercourse, vaginismus, and decreased sexual pleasure and fulfilment. It is difficult to assess the impact of FGM on women's sexual fulfilment however, as each individual woman with FGM will be affected differently. Factors such as the type of FGM and the amount of tissue removed, the extent of scarring, the experience of the initial procedure, cultural and social expectations, and affection and bonding in sexual relationships will all impact directly on sexuality and sexual functioning.
There are a range of childbirth complications that can be associated with FGM, particularly with Type 3 FGM (infibulation). The extent of the complications varies depending on factors such as the type of FGM, parity, and the nature of the scar tissue. Complications that can occur following infibulation, particularly amongst primigravidas, are as follows:
in the event of a miscarriage the foetus may be retained in the uterus or the birth canal, and performing a dilation and curettage maybe difficult
incorrect assessment of the stage of labour, cervical dilation, and foetal presentation due to the inability to perform vaginal examinations
inability to perform an induction with prostaglandins due to the very narrow introitus
difficulty applying a foetal scalp electrode, performing a foetal blood sample, or inserting a urinary catheter due to the very narrow introitus
difficulty identifying some obstetric emergencies such as cord prolapse due to an inability to perform a vaginal examination
increased risk of bleeding, wound infection, and damage to surrounding tissues due to repeated deinfibulation, particularly if it is not performed correctly
prolonged and obstructed labour due to partial or total occlusion of the vaginal opening. This can lead to increased risk of uterine inertia, rupture or prolapse, tearing to the perineum, haemorrhage, and fistula formation. The baby may have an increased risk of suffering neonatal brain damage or death as a result of birth asphyxia
repetition of deinfibulation and reinfibulation weakens the scar tissue and at the beginning of menopause a woman may have a mass of fibrous tissue resulting in incontinence and prolapses of the vaginal wall.
There is very limited research on the impact of FGM on psychological health. The research that has been conducted is sparse and as FGM is condoned in many of the countries where it is practiced, research is likely to have been limited by social and cultural restrictions on the exploration of any negative impacts of the practice.
Some of the negative psychological effects that have been reported include feelings of anxiety, fear, bitterness and betrayal, loss of trust, suppression of feelings, feelings of incompleteness, loss of self esteem, panic disorders and difficulty with body image. When considering the psycho-social consequences of FGM, it is important to balance the traumatic impact of the initial FGM procedure and its long-term sequelae, against the social and cultural benefits that FGM brings to young girls in the communities where it is practiced.
Treatment for FGM (deinfibulation)
Surgery can be performed to open up the vagina, if necessary. This is called deinfibulation.
It's sometimes known as a "reversal" although this name is misleading, as the procedure doesn’t replace any removed tissue, and will not undo the damage caused. However, it can help many problems caused by FGM.
Surgery may be recommended for:
women who are unable to have sex or have difficulty passing urine as a result of FGM
pregnant women at risk of problems during labour or delivery as a result of FGM
Deinfibulation should be carried out before getting pregnant, if possible. It can be done in pregnancy or labour if necessary, but ideally should be done before the last two months of pregnancy. The surgery involves making a cut (incision) to open the scar tissue over the entrance to the vagina.
It's usually performed under local anaesthetic in a clinic and you won't normally need to stay overnight. A small number of women need either a general anaesthetic or spinal anaesthetic (injection in the back), which may involve a short stay in hospital.
Why is FGM performed?
In every society in which it is practiced, female genital mutilation is a manifestation of deeply entrenched gender inequality. Where it is widely practiced, FGM is supported by both men and women, usually without question, and anyone that does not follow the norm may face condemnation, harassment and ostracism. It may be difficult for families to abandon the practice without support from the wider community. In fact, it is often practiced even when it is known to inflict harm upon girls because the perceived social benefits of the practice are deemed higher than its disadvantages.
The reasons given for practicing FGM fall generally into five categories:
Psycho-sexual reasons: FGM is carried out as a way to control women’s sexuality, which is sometimes said to be insatiable if parts of the genitalia, especially the clitoris, are not removed. It is thought to ensure virginity before marriage and fidelity afterward, and to increase male sexual pleasure.
Sociological and cultural reasons: FGM is seen as part of a girl’s initiation into womanhood and as an intrinsic part of a community’s cultural heritage. Sometimes myths about female genitalia (e.g., that an uncut clitoris will grow to the size of a penis, or that FGM will enhance fertility or promote child survival) perpetuate the practice.
Hygiene and aesthetic reasons: In some communities, the external female genitalia are considered dirty and ugly and are removed, ostensibly to promote hygiene and aesthetic appeal.
Religious reasons: Although FGM is not endorsed by either Islam or by Christianity, supposed religious doctrine is often used to justify the practice.
Socio-economic factors: In many communities, FGM is a prerequisite for marriage. Where women are largely dependent on men, economic necessity can be a major driver of the procedure. FGM sometimes is a prerequisite for the right to inherit. It may also be a major income source for practitioners.
Since FGM is part of a cultural tradition, can it still be condemned?
Yes. Culture and tradition provide a framework for human well-being, and cultural arguments cannot be used to condone violence against people, male or female. Moreover, culture is not static, but constantly changing and adapting. Nevertheless, activities for the elimination of FGM should be developed and implemented in a way that is sensitive to the cultural and social background of the communities that practice it. Behaviour can change when people understand the hazards of certain practices and when they realize that it is possible to give up harmful practices without giving up meaningful aspects of their culture.
What does the term “medicalization of FGM” mean?
According to WHO, the medicalization of FGM is when FGM is performed by a health-care provider, such as a community health worker, midwife, nurse or doctor.
Medicalized FGM can take place in a public or private clinic, at home or elsewhere. It also includes the procedure of reinfibulation at any point in time in a woman’s life.
Isn’t it safer for FGM to be performed by a skilled health worker rather than by somebody without a medical background?
FGM can never be “safe”. Even when the procedure is performed in a sterile environment and by a health-care professional, there can be serious health consequences immediately and later in life. Medicalized FGM gives a false sense of security. There are serious risks associated with all forms of FGM, including medicalized FGM. There is no medical justification for FGM. Advocating any form of cutting or harm to the genitals of girls and women, and suggesting that medical personnel should perform it is unacceptable from a public health and human rights perspective. Trained health professionals who perform female genital mutilation are violating girls’ and women’s rights to life, physical integrity and health. They are also violating the fundamental medical ethic to “do no harm.”
When medical personnel perform FGM, they wrongly legitimize the practice as medically sound or beneficial for girls and women’s health. And because medical personnel often hold power, authority and respect in society, it can also further institutionalize the procedure.
In which countries is FGM banned by law?
Africa: Benin (2003); Burkina Faso (1996); Central African Republic (1996, 2006); Chad (2003); Cote d'Ivoire (1998); Djibouti (1994, 2009); Egypt (2008); Eritrea (2007); Ethiopia (2004); The Gambia (2015); Ghana (1994, 2007); Guinea (1965, 2000); Guinea Bissau (2011); Kenya (2001, 2011); Mauritania (2005); Niger (2003); Nigeria (2015); Senegal (1999); South Africa (2000); Sudan (state of South Kordofan 2008, state of Gedaref 2009); Tanzania (1998); Togo (1998); Uganda (2010); Zambia (2005, 2011)
Others: Australia (6 out of 8 states between 1994-2006); Austria (2002); Belgium (2000); Canada (1997); Colombia (Resolution No. 001 of 2009 by indigenous authorities); Cyprus (2003); Denmark (2003); France (Penal Code, 1979); Italy (2005); Luxembourg (on mutilations only, not specifically on 'genital' mutilation, 2008); New Zealand (1995); Norway (1995); Portugal (2007); Spain (2003); Sweden (1982, 1998); Switzerland (2005, new stricter penal norm in 2012); United Kingdom (1985); United States (1996).
Penalties range from a minimum of six months to a maximum of life in prison. Several countries also include monetary fines in the penalty.
There is need to eradicate FGM in the world at large. Education of the general public at all levels with emphasis on the dangers and undesirability of FGM is paramount.
At the grassroots, efforts should be taken to join in the crusade to say “NO” to FGM anywhere it is practiced among people. It is crude, dangerous, wicked and unhealthy. FGM is not required by any religion and there is no scientific evidence that women who have been mutilated are more faithful or better wives than those who have not undergone the procedure. It is very clear that there is no single benefit derived from FGM.
Join the crusade to say “NO” to save the future generations of women.
Enquire about the practice in your locality and give clear information and education to other people on the health effects of FGM.
Work with other people to stop the practice in your area. Contact health or other influential authorities in your area to notify them about the problem.
Discuss with your law makers or local representatives on making laws against FGM.
Support families and communities in their efforts to abandon the practice and to improve care for those who have undergone FGM.