Terminology
The term “female genital mutilation/cutting” (FGM/C) refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for nonmedical reasons. The terminology for these procedures has undergone various changes over the last few decades. The term “female circumcision” was widely used for many years to describe the practice; it has been largely abandoned, however, as it implies an analogy with the circumcision of newborn boys, a low-risk procedure with medical benefits. , The expression “female genital mutilation” gained growing support from women’s rights and health advocates in the late 1970s to emphasize the serious harm associated with the practice and to define it as a violation of girls’ and women’s human rights. The World Health Organization (WHO) recommended that the United Nations (UN) adopt this term in 1991 and it has subsequently been widely used by WHO and in other UN documents.
In the mid-1990s many practicing communities and activists decided to use a more neutral term, “female genital cutting” (FGC), because they considered the term FGM to be stigmatizing to those who had undergone the procedure. In addition, it appeared that the word was estranging practicing communities and perhaps hindering the process of social change necessary for the elimination of FGM.
While the UN continues to use FGM in official documents, some of its agencies (United Nations Children’s Fund [UNICEF] and United Nations Population Fund [UNFPA]) have started to use the combined term female genital mutilation/cutting (FGM/C) to capture the significance of the term “mutilation” at the policy level and at the same time to use less judgmental terminology for practicing communities. It is important that health care providers use culturally sensitive terms with patients when discussing this practice and its consequences.
Prevalence and Geographic Distribution
The World Health Organization estimates that between 100 million and 140 million girls and women worldwide have undergone some type of FGM, and that currently, about 3 million girls, most of them under 15 years of age, undergo the procedure every year. The great majority of affected women live in 28 countries in Africa, but the practice has also been reported in parts of the Middle East, Asia, and Latin America. Countries on the African continent with the highest likelihood of FGM being practiced are Djibouti, Egypt, Eritrea, Ethiopia, Gambia, Guinea, Mali, Sierra Leone, Somalia, and Sudan.
Growing migration has increased the number of girls and women living outside their country of origin; many who now live in Europe, the United States, Canada, New Zealand, and Australia have undergone FGM or may be at risk of being subjected to the practice. Some families arrange for their daughters to undergo FGM while on vacation in their home countries.
Female genital mutilation is practiced by people from all education levels and social classes, including urban and rural residents, and different religious and ethnic groups. It is generally practiced on girls between the ages of 4 and 10 years, although in some communities it is performed shortly after birth, during adolescence, just before marriage, during first pregnancy, or after the first birth. In some practicing cultures, women are re-infibulated (re-stitched) following childbirth as a matter of routine. The age at which female genital mutilation is performed varies with local traditions and circumstances, and is reported to be decreasing in some countries.
The procedure is usually performed by traditional birth attendants or older women in the community who do not have formal training. It is often carried out using primitive instruments, razor blades or pieces of glass, and without anesthetic or attention to hygiene. The child can be subjected to the procedure unexpectedly and held down on the floor by several attendants. Often a number of girls undergo the procedure during a single ritual ceremony and in these cases the same instrument is commonly used on all the girls. Increasingly, in some communities, FGM is being “medicalized” and performed in modern clinical settings by a physician or other health professional in the belief that complications occur less frequently.
Types of Female Genital Mutilation
Recognition of the different types of FGM is important because the complications differ with the severity of the procedure.
The WHO/UNICEF/UNFPA 1997 Joint Statement classifies FGM into four types based on the severity of structural disfigurement. This was slightly modified in 2008. Within each type of FGM there will be variation with respect to the amount of tissue removed. Table 17-1 lists the classifications of FGM. Figure 17-1 represents normal, unmutilated female genitalia. Figures 17-2, 17-3, and 17-4 represent various types of FGM. Current estimates indicate that about 90% of female genital mutilation cases include Types I or II and IV and about 10% are Type III.
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* Note that in French the term “excision” is often used as a general term covering all types of female genital mutilation.
† Reinfibulation is covered under this definition. This is a procedure to recreate an infibulation usually after childbirth in which defibulation was necessary.
The type of FGM varies by region and ethnicity. In reality, the extent of cutting and stitching varies considerably since the excisor is usually a layperson with limited knowledge of anatomy and surgical technique. With local or no anesthesia, the girls often move to the extent that cutting cannot be accurately controlled.
Cultural Issues
It is not known when or where the tradition of FGM originated. Evidence from Egyptian mummies suggests that infibulation (also known as the pharaonic procedure) was practiced there some 5000 years ago. Cliteroidectomy was used in western medicine up to the late 1950s as a treatment for nymphomania, promiscuity, and masturbation. ,
FGM continues within a complex web of social, cultural, and economic justification and is deeply embedded in local traditional belief systems. These beliefs involve continuing long-standing custom and tradition, maintaining virginity, enhancement of girls’ ability to marry, promotion of fidelity in married women, enhancement of male sexual pleasure, increasing fertility and child survival, upholding family honor, perceived religious dictates, and contributing to social stability.
Preservation of Cultural Identity
In communities where it is widely practiced, FGM is considered an honorable tradition that is an important part of the cultural identity of girls and women. In some societies, the practice is embedded in coming-of-age rituals and girls who undergo the procedure are given rewards such as celebrations, public recognition, and gifts.
Marriage
Some of the other justifications offered for FGM are also linked to girls’ marriage prospects. Marriage is essential to the social and economic security for women in FGM practicing communities. FGM becomes a physical sign of virginity and is regarded in many societies as a prerequisite for an honorable marriage. In some communities, it is thought to restrain sexual desire, thereby ensuring marital fidelity. A belief sometimes expressed is that FGM enhances a man’s sexual pleasure.
Religion
While religious duty is commonly cited as justification for the practice of FGM, it is important to note that FGM is a cultural and not a religious requirement. Even though the practice can be found among Christians, Jews, and Muslims, none of the holy texts of any of these religions prescribes FGM and the practice predates both Christianity and Islam.
Health
FGM is thought to improve fertility and prevent infant and maternal mortality.
Hygiene and Aesthetic Reasons
FGM is also considered to promote cleanliness. In some cultures it is believed that a girl who has not undergone FGM is unclean and not able to handle food or drink. Removal of genital parts is thought of as eliminating “masculine” parts such as the clitoris or in the case of infibulations, to achieve smoothness which is considered to be beautiful.
Contributing to Social Stability
The practice of FGM is often upheld by local structures of power and authority such as traditional leaders, religious leaders, circumcisers, elders, and even some medical personnel. It can be a lucrative source of income in some communities. It is often practiced even when known to inflict harm upon girls because the perceived social benefits of the practice are deemed higher than its disadvantages. Parents who support the practice of FGM say that they are acting in the child’s best interests and risk their child’s marriage prospects and being ostracized by their community should they resist the practice.
Health Complications
A wide range of complications of FGM are documented, including short-term and long-term physical, sexual, and psychosocial problems. The type and severity of the consequences vary according to the type of procedure performed; the extent of the cutting; the skill of the incisor; the hygienic conditions; the physical and mental health of the girl undergoing the procedure; the child’s access to adequate health care; and particular characteristics of the child, including age, ethnicity, and family and societal support.
For many women the most difficult physical problems coincide with various life cycle events such as immediately after cutting, at menstruation, at time of marriage, and during childbirth. The physical complications are summarized in Table 17-2 .
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