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Female genital mutilation

Road sign near Kapchorwa, Uganda
Description	Partial or complete removal of the external female genitalia, or other injury to the female genital organs, for non-medical reasons
Other names	Female genital cutting, circumcision, genital surgeries, genital alteration, genital excision, genital modification
Areas practiced	28 countries in West, East, North and sub-Sarahan Africa; parts of Asia and the Middle East
Number affected	140 million worldwide as of 2013, including 101 million in Africa
Age performed	A few days after birth to age 15; occasionally in adulthood

Female genital mutilation (FGM), also known as female genital cutting (FGC) and female circumcision (FC), is defined by the World Health Organization (WHO) as "all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons." It is practiced mainly in 28 countries in western, eastern, and north-eastern Africa, particularly Egypt and Ethiopia, and in parts of Asia and the Middle East. The WHO estimates that 140 million women and girls around the world have experienced it, including 101 million in Africa.

FGM is typically carried out between four years old and puberty, although it may be conducted on younger infants and adults. It may take place in a hospital, but is usually performed without anaesthesia by a traditional circumciser using a knife, razor or scissors. The practice is rooted in gender inequality, cultural identity, ideas about purity, modesty, aesthetics, status and honor, and attempts to control women's sexuality by reducing their sexual desire, thereby promoting chastity and fidelity. In communities that practice it, it is typically supported by both women and men.

The WHO offers four classifications of FGM. Type I usually refers to removal of the clitoris (clitoridectomy) and clitoral hood. Type II (excision) is removal of the clitoris and inner labia. Type III (infibulation) involves the removal of all or part of the inner and outer labia, and usually the clitoris, and the fusion of the wound; a small hole is left for the passage of urine and menstrual blood, and the wound is opened for intercourse and childbirth. Around 85 percent of women who undergo FGM experience Types I and II. Type III is the most common procedure in Djibouti, Somalia and Sudan, and in parts of Eritrea, Ethiopia and Mali. Type IV refers to miscellaneous procedures such as symbolic piercing of the clitoris or labia, cauterization of the clitoris, and cutting into the vagina to widen it (gishiri cutting).

The health consequences of FGM can include recurrent urinary and vaginal infections, chronic pain, infertility, fatal hemorrhaging, epidermoid cysts, and complications during childbirth. Opposition to it focuses on the health issues, rights violations and lack of informed consent; in 2012 the United Nations General Assembly unanimously passed a resolution banning it. Sylvia Tamale, a Ugandan legal scholar, writes that there is a large body of research and activism in Africa that strongly opposes FGM, but she cautions that some African feminists object to what she calls the imperialist infantilization of African women, and the idea that FGM is nothing but a barbaric rejection of modernity. Tamale suggests that there are cultural and political aspects to the practice's continuation that make opposition to it a complex issue.

Terminology

The procedures known as FGM were referred to as female circumcision (FC) until the early 1980s, when the term female genital mutilation came into use. That term was adopted at the third conference of the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children in Addis Ababa, Ethiopia, and in 1991 the WHO recommended its use to the United Nations. It has since become the dominant term within the international community and in medical literature. Alexia Lewnes argued in a 2005 report for UNICEF that the word mutilation differentiates the procedure from male circumcision and stresses its severity. Medical or elective procedures such as labiaplasty and vaginoplasty, or those used in sex reassignment surgery, are not regarded as examples of FGM. According to the WHO, some elective practices in countries that have outlawed FGM do fall under the category of Type IV, but it maintains a broad definition to avoid creating loopholes.

Other terms in use include female genital cutting (FGC), female genital surgeries, female genital alteration, female genital excision, and female genital modification. Elizabeth Heger Boyle writes that some organizations refer to it as FGC because the communities that practise it do not see themselves as engaging in mutilation; she writes that state-sponsored groups tend to call it FGM, while private groups use FGC. Other groups, such as UNFPA and USAID, use the combined term female genital mutilation/cutting (FGM/C).

Local terms include tahara in Egypt, tahur in Sudan, and bolokoli in Mali, which Anika Rahman and Nahid Toubia write are words synonymous with purification. It is also known as kakia, and in Sierra Leone as bundu, after the Bundu secret society. Several countries refer to Type I as sunna circumcision. A sunna kashfa in the Sudan involves cutting off half the clitoris. Type III (infibulation) is known as pharaonic circumcision in Sudan, and as Sudanese circumcision in Egypt. There is a form of Type III practised in Sudan called matwasat, which involves the same degree of cutting, but less stitching, so the remaining hole is larger. Urologist Jean Fourcroy writes that women in countries that practise FGM call it one of the "three feminine sorrows": the first sorrow is the procedure itself, followed by the wedding night when a woman with Type III has to be cut open, then childbirth when she has to be cut again.

Health effects

FGM is typically carried out by traditional practitioners, without anaesthesia, using unsterile cutting devices such as knives, razors, scissors, cut glass, sharpened rocks, and fingernails, and applying suturing material such as agave or acacia thorns. Affluent women in urban settings may undergo the procedure in a safer medical environment.

FGM has immediate and late complications. Immediate complications are increased when FGM is performed in traditional ways, and without access to medical resources: the procedure is extremely painful and a bleeding complication can be fatal. Other immediate complications include acute urinary retention, urinary infection, wound infection,septicemia, tetanus, and in case of unsterile and reused instruments, hepatitis and HIV. According to a 2005 UNICEF report by Alexia Lewnes, it is unknown how many girls and women die from the procedure; she writes that few records are kept, complications may not be recognized, and fatalities are rarely reported. A film shot in Lunsar, Sierra Leone, by Mariana van Zeller in 2007 discusses how girls who bleed excessively are regarded as witches.

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 sequalae include damage to urethra and bladder with infections and incontinence. Genital tract sequelae include vaginal and pelvic infections, dysmenorrhea, dyspareunia and infertility. Complete obstruction of the vagina results in hematocolpos and hematometra. Other complications include epidermoid cysts that may become infected, neuroma formation, typically involving nerves that supplied the clitoris, and pelvic pain.

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

Psychological complications are related to cultural context; damage may occur to women who undergo FGM particularly when they are moving outside their traditional circles and are confronted with a view that mutilation is not the norm. Women with FGM typically report sexual dysfunction and dyspareunia (painful sexual intercourse), but several researchers have written that FGM does not necessarily destroy sexual desire in women. Elizabeth Heger Boyle reported several studies during the 1980s and 1990s where the women said they were able to enjoy sex, though with Type III the risk of sexual dysfunction was higher.

Reasons for the practice

The practice continues because of cultural and religious factors that vary from country to country and region to region. It is considered by its practitioners to be an essential part of raising a girl. Women themselves may insist on it for their daughters, or for themselves as adults, including before or after childbirth (when women with Type III are closed again, or "reinfibulated"). Miriam Martinelli and Jaume Enric Ollé-Goig write that reasons for the practice can be divided into five categories:

Hygienic and aesthetic. The external female genitalia are considered dirty and "unsightly" and should be flat, rigid and dry;

Sociological. Identification with the cultural traditions, as a rite of passage of girls into womanhood, and for the maintenance of social cohesion;

Psychological. Reduction of sensitive tissue and thus to curb sexual pleasure in order to maintain chastity and virginity, to guarantee women's fidelity, and even to increase male sexual pleasure;

Myths and false beliefs. To enhance fertility and promote child survival; and

Religious. FGM/C has been practiced in a range of communities with different religions: Christian, Muslim and animist. Muslim communities often have the false belief that FGM/C is related to teachings of the Islamic law.

Susan Izett and Nahid Toubia write that pain and trauma are central to defining "appropriate female disposition and concepts of 'morally appropriate fertility,'" and that any change to the state of her mutilation can affect a woman's sense of identity and security. They cite the case of a Somali mother of three who was advised to remain defibulated to cure her gonorrhoea, but who insisted on being re-infibulated, leading to pain and infection so severe she could hardly walk. Izett and Toubia write that she did this because of "her own sense of impurity," not for her husband's benefit. According to Toubia, a Sudanese surgeon and president of RAINBO (Research, Action and Information Network for the Bodily Integrity of Women), women with FGM see themselves as "heightened to another level of pure motherhood – a motherhood not tainted by sexuality and that is why the woman gives it away to become the matron, respected by everyone." She argues that, as a result, it is much harder to convince the women to give up FGM than it is the men. Elizabeth Heger Boyle writes that the Masai Nilotes of Tanzania will not call a woman "mother" when she has children if she is uncircumcised.

In some societies, the procedure is performed to differentiate between the genders based on the belief that the clitoris confers masculinity on a girl and the foreskin of a boy makes him feminine. Ellen Gruenbaum writes that in Sudan the clitoris and labia (the "masculine" parts) are viewed as ugly, and the smooth, infibulated vulva as feminine. One group of women told an interviewer: "Which is better, an ugly opening or a dignified closure?" David Gollaher writes that various myths cite the clitoris as dangerous: able to harm a man if his penis touches it, and cause excess cranial fluid in a baby, or poison breast milk in the mother, if the baby touches it during birth. According to Amnesty, women who have not had the procedure are regarded in certain societies as too unclean to handle food and water, and there is a belief that a woman's genitals might continue to grow without FGM, until they dangle between her legs. There may also be economic advantages to having the procedure; girls who undergo FGM are sometimes showered with gifts from the community, which provides an additional motivation.

Historian Lynn Thomas writes that the ritual around FGM has been the "primary context" in some communities in which the women come together (quoting the anthropologist Corinne Kratz). Because they see it as a way of moving from girlhood to womanhood, and a way of differentiating between each other, Thomas argues that to remove FGM is to remove that opportunity to gain authority. She writes that "eradicationists" have responded to this by strengthening their relationships with local anti-FGM activists. For example, one of the issues that keeps FGM going in some communities is that the practitioners have no other way to earn a living. Organizations working to end it are therefore offering the women training of some kind; teaching them how to become farmers, for example.

There is a misperception that the practice is an Islamic one. The likelihood of having experienced FGM increases with the Muslim population, but it is not a religious requirement, although Islamic scholars debate the extent to which it is regarded as desirable. Several Muslim leaders have campaigned for its abandonment, and a former mufti of Sudan issued a fatwa (religious ruling) against infibulation (Type III). Judaism requires circumcision for boys, but does not allow it for girls.

Classification

Age performed, circumcisers

The age at which the procedure is performed varies. Comfort Momoh writes that in Ethiopia the Falashas perform it when the child is a few days old, the Amhara on the eighth day of birth, while the Adere and Oromo choose between four years and puberty. In Somalia it is done between four and nine years. Other communities may wait until adulthood, she writes, either just before marriage or just after the first pregnancy. It may be carried out on one girl alone, or on a group of girls at the same time.

The procedure is generally performed by a traditional circumciser, usually an older woman known as a "gedda," without anaesthesia or sterile equipment, though richer families may pay instead for the services of a nurse, midwife, or doctor using a local anaesthetic. It may also be performed by the mother or grandmother, or in some countries – such as Nigeria and Egypt – by the local male barber.

Types I and II

The WHO divides FGM into four categories (see image below right for Types I–III). Around 85 percent of women experience Types I and II, and 15 percent Type III.

Type I is the removal of the clitoral hood (Type Ia), which is rarely performed alone; or the partial or total removal of the clitoris, a clitoridectomy (Type Ib).

Type II, often called excision, is partial or total removal of the clitoris and the inner labia or outer labia. Type IIa is removal of the inner labia only; Type IIb, partial or total removal of the clitoris and the inner labia; and Type IIc, partial or total removal of the clitoris, and the inner and outer labia.

Type III

Type III, commonly called infibulation, is the removal of all external genitalia. The inner and outer labia are cut away, with or without excision of the clitoris. Martha Nussbaum writes that Type III accounts for 80–90 percent of all such procedures in countries such as Sudan, Somalia, and Dijbouti.

After the procedure the girl's legs are tied together from hip to ankle for 15–40 days to allow the wound to heal. The immobility causes the labial tissue to bond, forming a wall of flesh and skin across the vulva, apart from a hole the size of a matchstick for the passage of urine and menstrual blood, which is created by inserting a twig or rock salt into the wound. There is another form of Type III called matwasat, where the stitching of the vulva is less extreme and the hole left is bigger. Momoh describes a Type III procedure:

In Type 3 excision or infibulation ... elderly 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.

The vulva is cut open for sexual intercourse and childbirth. Momoh writes that, in some communities, when a pregnant woman who has not experienced FGM goes into labour, the procedure is performed before she gives birth, because it is believed the baby may be stillborn if it touches her clitoris. The risk of haemorrhage and death from FGM during labour is high, she writes. During three six-month studies in the 1980s, Hanny Lightfoot-Klein interviewed 300 Sudanese women and 100 Sudanese men, and described the penetration by the men of their wives' infibulation:

The penetration of the bride's infibulation takes anywhere from 3 or 4 days to several months. Some men are unable to penetrate their wives at all (in my study over 15%), and the task is often accomplished by a midwife under conditions of great secrecy, since this reflects negatively on the man's potency. Some who are unable to penetrate their wives manage to get them pregnant in spite of the infibulation, and the woman's vaginal passage is then cut open to allow birth to take place. A great deal of marital anal intercourse takes place in cases where the wife can not be penetrated – quite logically in a culture where homosexual anal intercourse is a commonly accepted premarital recourse among men – but this is not readily discussed. 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.

Type IV

A variety of other procedures are collectively known as Type IV, which the WHO defines as "all other harmful procedures to the female genitalia for non-medical purposes, for example, pricking, piercing, incising, scraping and cauterization." This ranges from ritual nicking of the clitoris – the main practice in Indonesia – to stretching the labia or clitoris, burning or scarring the genitals, or introducing harmful substances into the vagina to tighten it.

Stanlie M. James writes that Mairo Usman Mandara, a Nigerian surgeon, has described several practices that involve cutting internal genitalia (introcision). These include hymenotomy, the removal of a hymen regarded as too thick; James writes that this is practised by the Hausa in West Africa. They also include gishiri cutting, where the vagina's anterior wall is cut with a razor blade or penknife to enlarge it; according to James, this might be done during obstructed labor or to address other medical issues. Izett and Toubia write that it often results in vesicovaginal fistulae and damage to the anal sphincter.

Reinfibulation and defibulation

Women may request reinfibulation (RI) – the restoration of the infibulation – after giving birth, a contentious issue, with surgeons who perform the procedure regarded as behaving unethically and probably illegally. In Sudan, RI is known as El-Adel (re-circumcision or, literally, "putting right" or "improving"). Two cuts are made around the vagina, then sutures are put in place to tighten it to the size of a pinhole. Vanja Bergrren writes that this in effect mimics virginity. RI may also be carried out just before marriage, after divorce, or even in elderly women to prepare them for death.

Defibulation, or deinfibulation, is a surgical technique to reverse the closure of the vaginal opening after a Type III infibulation, and consists of a vertical cut opening up normal access to the vagina. This may be accompanied by removal of scar tissue and labial repair. Procedures have been developed to repair clitoral integrity, such as by Pierre Foldes, a French urologist and surgeon, and Marci Bowers, an American surgeon who studied his work; they used intact clitoral tissue from inside women's bodies to form a new clitoris.

Epidemiology

According to the WHO, 140 million women and girls are living with the effects of FGM, including 101 million girls over the age of 10 in Africa, where the practice persists in 28 countries. Caldwell, Orubuloye and Caldwell write that 80–88 percent of women in Africa who have experienced FGM live in sub-Saharan Africa, 51 percent in West Africa and 27 percent in Nigeria.

The highest prevalence rates are Somalia (97.9 percent of women), Egypt (95.8 percent), Guinea (95.6 percent), Sierra Leone (94 percent), Djibouti (93.1 percent), Mali (91.6 percent) and Eritrea (88.7 percent). According to the WHO, nearly half the women who have undergone it live in Egypt and Ethiopia.

Outside Africa, FGM occurs in Indonesia, Malaysia, Iran, Iraq, Oman and Yemen. It is also found among immigrant communities in Australia and New Zealand, Europe, Scandinavia, the United States and Canada.

Opposition and legislation

Colonial opposition in Kenya

Anika Rahman and Nahid Toubia write that attempts in the early 20th century by colonial administrators to halt FGM succeeded only in provoking local anger. In Kenya, Christian missionaries in the 1920s and 1930s forbade their adherents from practising it – in part because of the medical consequences, but also because the accompanying rituals were seen as highly sexualized – and as a result it became a focal point of the independence movement among the Kikuyu, the country's main ethnic group. One American missionary, Hilda Stump, was murdered in January 1930 after speaking out against it.

Historian Lynn M. Thomas writes that the period 1929–1931 became known in Kenyan historiography as the female circumcision controversy. Protestant missionaries campaigning against it tried to gain support from humanitarian and women's rights groups in London, where the issue was raised in the House of Commons, and in Kenya itself a person's stance toward FGM became a test of loyalty, either to the Christian churches or to the Kikuyu Central Association. Jomo Kenyatta (c. 1894–1978), who became Kenya's first prime minister in 1963, wrote in 1930:

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

Support for the practice also came from the women themselves. E. Mary Holding, a Methodist missionary in Meru, Kenya, wrote in 1942 that the ritual was an entirely female affair, organized by women's councils known askiama gia ntonye ("the council of entering"). The procedure saw the girls become women, and allowed their mothers to become members of the women's council, a position of authority.

Similarly, prohibition strengthened tribal resistance to the British in the 1950s, and increased support for the Mau Mau Uprising (1952–1960). In 1956, under pressure from the British, the council of male elders (the Njuri Nchecke) in Meru, Kenya, announced a ban on clitoridectomy. Over two thousand girls – mostly teenagers, but some as young as eight – were charged over the next three years with having carried out the procedure on each other with razor blades, a practice that came to be known as Ngaitana ("I will circumcise myself"), so-called because the girls claimed to have cut themselves to avoid naming their friends. Political scientist Jane Bennett argues that this was done not only in defiance of the council's cooperation with the colonial authorities, but also in protest against its interference with women's decisions about their own rituals. Thomas describes the episode as significant in the history of FGM because it made clear that its apparent victims were in fact its central actors.

Opposition since the 1970s

In the 1960s and 1970s, Rahman and Nahid Toubia write, doctors in Sudan, Somalia, and Nigeria began to speak out about the health consequences of FGM, and opposition gathered pace during the United Nations Decade for Women (1975–1985). In 1979 the American feminist writer Fran Hosken (1920–2006) presented research about it – The Hosken Report: Genital and Sexual Mutilation of Females (1979) – to the first Seminar on Harmful Traditional Practices Affecting the Health of Women and Children, sponsored by the WHO. Rahman and Toubia write that African women from several countries led a vote to end the practice.

In 1980 and 1982 feminist physicians Nawal El Saadawi and Asma El Dareer wrote about FGM as a dangerous practice intended to control women's sexuality. The decade saw the framing of FGM – along with issues such as dowry deaths – as a human rights violation rather than a health concern, and this encouraged academic interest, including from feminist legal scholars. In June 1993 the Vienna World Conference on Human Rights agreed that FGM was a violation of human rights.

Several African countries have enacted legislation against it since 1994, including Benin, Burkina Faso, Central African Republic, Chad, Djibouti, Eritrea, Ethiopia, Ghana, Ivory Coast, Kenya, Niger, Senegal, Tanzania, Togo and Uganda. President Daniel Moi of Kenya issued a decree against it in December 2001. Egypt banned FGM in 2007 despite pressure from some Islamic groups. Two issues forced the government's hand. In 1995 a 10-year-old girl was photographed undergoing FGM in a barber's shop in Cairo and the images were broadcast by CNN; this triggered a ban on the practice everywhere except in hospitals. In 2007 12-year-old Badour Shaker died of an overdose of anaesthesia during or after an FGM procedure for which her mother had paid a physician in an illegal clinic the equivalent of $9.00. The Al-Azhar Supreme Council of Islamic Research, the highest religious authority in Egypt, issued a statement that FGM had no basis in core Islamic law, and this enabled the government to outlaw it entirely. Similarly, in Mauritania, where over 70 percent of girls undergo FGM, 34 Islamic scholars signed a fatwa (religious opinion) in January 2010 banning the practice.

Since 2003 the United Nations has sponsored an International Day of Zero Tolerance to Female Genital Mutilation, held every 6 February. In December 2012 the United Nations General Assembly unanimously passed a resolution banning the practice.

Some of the international opposition to FGM has attracted critics. Fran Hosken's The Hosken Report, in particular, was criticized for its alleged ethnocentrism, negative statements about African society, and insistence on Western intervention. Sylvia Tamale wrote in 2011 that some African feminists interpret traditional practices such as FGM within a post-colonial context that makes opposing them a complex issue. While themselves critical of FGM, they object to what Tamale calls the imperialist infantilization of African women inherent in some of the Western criticism.

Non-practicing countries

As a result of immigration, FGM spread to Australia, Canada, Europe (particularly France and the UK, because of immigration from former colonies), New Zealand, Scandinavia and the United States. As Western governments became more aware of the practice, legislation was passed to make it a criminal offence. Sweden passed legislation in 1982, the first Western country to do so. It is outlawed in Australia and New Zealand, across the European Union, and is a crime under section 268 of the Criminal Code of Canada.

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

In the United Kingdom, the Prohibition of Female Circumcision Act 1985 outlawed the procedure in Britain itself, and the Female Genital Mutilation Act 2003 and Prohibition of Female Genital Mutilation (Scotland) Act 2005 made it an offence for FGM to be performed anywhere in the world on British citizens or permanent residents. According to the Foundation for Women's Health, Research and Development (FORWARD) – founded in 1983 by Efua Dorkenoo, a Ghanaian campaigner against FGM –66,000 women in England and Wales have experienced FGM, with 7,000 girls at risk. The Times reported in 2009 that there are 500 victims of FGM every year in the UK. Families who have immigrated from practising countries may send their daughters back there to undergo FGM, ostensibly to visit a relative, or may fly in circumcisers known as "house doctors" because they conduct the procedure in people's homes. As of May 2013, the Crown Prosecution Service was examining five alleged cases with a view to bringing the first prosecution.

There have been prosecutions elsewhere in Europe, particularly in France, where there have been 40 trials since the 1980s, resulting in convictions against two practitioners and over 100 parents. There are thought to be up to 30,000 women in France who have experienced FGM, and thousands of girls at risk.

History

The physician and ethnologist Charles Seligman (1873–1940) suggested in 1913 that FGM derived from ceremonies performed by Hamito-Semitic people on the Red Sea coast, "radiat from the shore of the Red Sea westwards and southwards across Africa with ever diminishing intensity." The term pharaonic circumcision (as Type III, or infibulation, is known in Sudan) refers to the belief that FGM was practiced in Egypt under the Pharaohs. The term infibulation stems from the Roman practice of piercing the outer labia with a fibula, or brooch.

Mary Knight writes that the earliest extant literary reference to the procedure is from the Greek geographer Strabo (c. 64 BCE – c. 23 CE), who reported it after visiting Egypt around 25 BCE: "This is one of the customs most zealously pursued by them : to raise every child that is born and to circumcise the males and excise the females." There is an earlier reference on a sarcophagus in the Egyptian Museum dating to Egypt's Middle Kingdom, c. 2000–1700 BCE: "But if a man wants to know how to live, he should recite it every day, after his flesh has been rubbed with the b3d of an uncircumcised girl and the flakes of skin of an uncircumcised bald man." Knight adds that Egyptologists are uncomfortable with the translation of 'm't as "uncircumcised," because it offers no information about what might constitute the circumcised state. A heiroglyph of a woman in labour and the physical examination of mummies by Grafton Elliot Smith (1871–1937), the Australian pathologist, suggest that Type III was not performed, although as part of the mummification process, the skin of the outer labia was pulled toward the anus to form a covering over the pudendal cleft (possibly to prevent sexual violation), which gave the appearance of Type III FGM. Smith wrote that soft tissues were often removed by embalmers, or had simply deteriorated, so that it was not possible to determine from the mummies whether Types I and II had been practised.

The philosopher Philo of Alexandria (c. 20 BCE–50 CE) asked why God in the Book of Genesis (17:10) commanded that only boys be circumcised, contrasting that with the practice in Egypt at the time: "In the first place, 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."

Knight writes that there is only one extant reference from antiquity that suggests FGM might have been practised outside Egypt, but it is probably not a reference to FGM. Xanthus of Lydia wrote in a history of Lydia in the fifth-century BCE: "The Lydians arrived at such a state of delicacy that they were even the first to 'castrate' their women." Knight argues that the context suggests that "castrate" refers to a form of sterilization.

Political scientist Gerry Mackie writes that FGM in Northeast Africa became tied up with the slave trade. He reports that the missionary João dos Santos (d. 1622) wrote of a group in Somalia inhabiting Mogadishu's interior 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." Early travellers to Egypt also wrote that female slaves were subjected to FGM. Mackie suggests that patterns of slavery across Africa account for the patterns of FGM found there, so that " practice associated with shameful female slavery came to stand for honor."

Gynaecologists in 19th-century Europe and the United States would remove the clitoris to treat insanity and masturbation. The first reported clitoridectomy in the West was carried out in 1822 by a surgeon in Berlin, a Dr. Graefe, on a teenage girl regarded as an "imbecile" who was masturbating. Isaac Baker Brown (1812–1873), an English gynaecologist who was president of the Medical Society of London in 1865, believed that the "unnatural irritation" of the clitoris caused epilepsy, hysteria and mania, and would "set to work to remove whenever he had the opportunity of doing so," according to his obituary in the Medical Times and Gazette. Peter Lewis Allen writes that Brown's views caused outrage, and he died penniless after being expelled from the Obstetrical Society.

Notes

1. ^ "Female genital mutilation", World Health Organization, February 2013.
2. ^ For "female genital modification," see Gallo, Pia Grassivaro; Tita Eleanora; and Viviani, Franco. "At the Roots of Ethnic Female Genital Modification," in George C. Denniston and Pia Grassivaro Gallo (eds.). Bodily Integrity and the Politics of Circumcision. Springer, 2006, pp. 49–50.
   • For the rest, see Momoh, Comfort. Female Genital Mutilation. Radcliffe Publishing, 2005, p. 6.
3. ^ "An update on WHO's work on female genital mutilation (FGM)", World Health Organization, 2011, p. 2: "Most women who have experienced FGM live in one of the 28 countries in Africa and the Middle East – nearly half of them in just two countries: Egypt and Ethiopia. Countries in which FGM has been documented include: Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Cote d’Ivoire, Djibouti, Egypt, Eritrea, Ethiopia, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, Somalia, Sudan, Togo, Uganda, United Republic of Tanzania and Yemen. The prevalence of FGM ranges from 0.6% to 98% of the female population."
   • Rahman, Anika and Toubia, Nahid. Female Genital Mutilation: A Guide to Laws and Policies Worldwide. Zed Books, 2000 (hereafter Rahman and Toubia 2000), p. 7: "Currently, FC/FGM is practiced in 28 African countries in the sub-Saharan and Northeastern regions."
   • Also see "Eliminating Female Genital Mutilation", World Health Organization, 2008, p. 4: "Types I, II and III female genital mutilation have been documented in 28 countries in Africa and in a few countries in Asia and the Middle East."
4. ^ Toubia, Nahid. "Female Circumcision as a Public Health Issue", The New England Journal of Medicine, 331(11), 1994, pp. 712–716. Cite error: The named reference "toubia1994" was defined multiple times with different content (see the help page).
5. ^ Abdulcadira, Jasmine; Margairaz, C.; Boulvain, M; Irion, O. "Effectiveness of interventions designed to prevent female genital mutilation/cutting: a systematic review", Swiss Medical Weekly, 6(14), January 2011 (review); also available here.
6. Mackie, Gerry. "Ending Footbinding and Infibulation: A Convention Account", American Sociological Review, 61(6), December 1996, (pp. 999–1017), pp. 99–1000 (hereafter Mackie 1996):

   • Footbinding and infibulation correspond as follows. Both customs are nearly universal where practiced; they are persistent and are practiced even by those who oppose them. Both control sexual access to females and ensure female chastity and fidelity. Both are necessary for proper marriage and family honor. Both are believed to be sanctioned by tradition. Both are said to be ethnic markers, and distinct ethnic minorities may lack the practices. Both seem to have a past of contagious diffusion. Both are exaggerated over time and both increase with status. Both are supported and transmitted by women, are performed on girls about six to eight years old, and are generally not initiation rites. Both are believed to promote health and fertility. Both are defined as aesthetically pleasing compared with the natural alternative. Both are said to properly exaggerate the complementarity of the sexes, and both are claimed to make intercourse more pleasurable for the male."

   • For gender inequality, see Toubia, Nahid F. and Sharief, Eiman Hussein. "Female genital mutilation: have we made progress?", International Journal of Gynecology & Obstetrics, 82(3), September 2003, pp. 251–261:

   • "One of the great achievements of the past decade in the field of FGM is the shift in emphasis from the concern over the harmful physical effects it causes to understanding this act as a social phenomenon resulting from a gender definition of women's roles, in particular their sexual and reproductive roles. This shift in emphasis has helped redefine the issues from a clinical disease model ... to a problem resulting from the use of culture to protect social dominance over women's bodies by the patriarchal hierarchy."

   • For gender inequality, also see "Eliminating Female Genital Mutilation", World Health Organization, 2008, p. 5:

   • "In every society in which it is practised, female genital mutilation is a manifestation of gender inequality that is deeply entrenched in social, economic and political structures. Like the now- abandoned foot-binding in China and the practice of dowry and child marriage, female genital mutilation represents society’s control over women. Such practices have the effect of perpetuating normative gender roles that are unequal and harm women."

   • For gender inequality, also see Vaughn, Lisa. Psychology and Culture. Psychology Press, 2010, p. 40:

   • "Culturally, markers of gender inequality include female illiteracy, gender/earning ratio with women earning less than men, and prevalence of abuse against women (wife abuse, genital mutilation of girls, female infanticide, acid throwing, female elder abuse, honour killings, etc.)."

   • For cultural identity, and for the control of female sexuality, see Rahman and Toubia 2000, pp. 5–6:

   • "A fundamental reason advanced for female circumcision is the need to control women's sexuality ... FC/FGM is intended to reduce women's sexual desire, thus promoting women's virginity and protecting marital fidelity, in the interest of male sexuality. FC/FGM also results in the reduction of women's sexual fulfillment, thus aiding in the construction of parameters around women's sexuality."

7. "Eliminating Female Genital Mutilation", World Health Organization, 2008, pp. 4, 22–28.
   • See p. 4, and Annex 2, p. 24, for the classification into Types I, II, III, and IV.
   • See Annex 2, pp. 23–28, for a more detailed discussion of the classification.
   • See Annex 2, p. 24, for a discussion of Type IV.
8. ^ "Female Genital Mutilation", World Health Organization, February 2013: "1. Clitoridectomy: partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris)."
   • Susan Izett and Nahid Toubia write there are no medical reports of Type I being performed without removal of the clitoris. See Izett and Toubia, Female Genital Mutilation: An Overview. World Health Organization, 1998: "Type I. In the commonest form of this procedure the clitoris is held between the thumb and index finger, pulled out and amputated with one stroke of a sharp object. Bleeding is usually stopped by packing the wound with gauzes or other substances and applying a pressure bandage. Modern trained practitioners may insert one or two stitches around the clitoral artery to stop the bleeding."
   • Also see "Eliminating Female Genital Mutilation", World Health Organization, 2008, p. 4: "partial or total removal of the clitoris (clitoridectomy) and/or the clitoral hood."
9. ^ "Eliminating Female Genital Mutilation", World Health Organization, 2008, p. 4: "Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision)".
   • p. 24: "Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision). When it is important to distinguish between the major variations that have been documented, the following subdivisions are proposed: Type IIa, removal of the labia minora only; Type IIb, partial or total removal of the clitoris and the labia minora; Type IIc, partial or total removal of the clitoris, the labia minora and the labia majora. Note also that, in French, the term "excision" is often used as a general term covering all types of female genital mutilation."
10. ^ "Eliminating Female Genital Mutilation", World Health Organization, 2008, p. 4: "Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation)."
    • p. 24: "Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation). When it is important to distinguish between variations in infibulations, the following subdivisions are proposed: Type IIIa, removal and apposition of the labia minora; Type IIIb, removal and apposition of the labia majora."
    • For the hole for urine, and the wound being opened for intercourse and childbirth, see Elchalal, Uriel et al'. "Ritualistic Female Genital Mutilation: Current Status and Future Outlook", Obstetrical & Gynecological Survey, 52(10), October 1997, pp. 643–651.
11. Caldwell, John C.; Orubuloye, I.O.; and Caldwell, Pat. "Female Genital Mutilation: Conditions of Decline", Population Research and Policy Review, 19(3), June 2000 (pp. 233–254), p. 235.
    • For more information on Djibouti, see Martinelli, M. and Ollé-Goig, J.E. "Female genital mutilation in Djibouti, African Health Sciences, 12(4), December 2012: "In 1997 the Ministry of Health assisted with the United Nation Fund for Population (UNFP) promoted the “Project to Fight Female Circumcision” ... they demonstrated that FGM/C was almost universal among women in Djibouti (98.8 %) and that 68 % of them had been subjected to type III mutilation."
12. "Eliminating Female Genital Mutilation", World Health Organization, 2008, p. 4: "All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization."
13. ^ "United Nations bans female genital mutilation", UN Women, 20 December 2012.
14. Tamale, Sylvia. "Researching and theorising sexualities," in Sylvia Tamale (ed.). African Sexualities: A Reader. Fahamu/Pambazuka, 2011, pp. 19–20.
15. Rahman and Toubia 2000, p. x.
16. ^ "Eliminating Female Genital Mutilation", World Health Organization, 2008, p. 22.
17. Nussbaum, Martha. "Judging Other Cultures: The Case of Genital Mutilation," Sex and Social Justice. Oxford University Press, 1999 (hereafter Nussbaum 1999), p. 119.
18. Lewnes, Alexia (ed.). "Changing a harmful social convention: female genital cutting/mutilation", Innocenti Digest, UNICEF, 2005, pp. 1–2 (hereafter Lewnes/UNICEF 2005).
19. "Eliminating Female Genital Mutilation", World Health Organization, 2008, p. 28: "Some practices, such as genital cosmetic surgery and hymen repair, which are legally accepted in many countries and not generally considered to constitute female genital mutilation, actually fall under the definition used here. It has been considered important, however, to maintain a broad definition of female genital mutilation in order to avoid loopholes that might allow the practice to continue."
20. Boyle, Elizabeth Heger. Female Genital Cutting: Cultural Conflict in the Global Community. Johns Hopkins University Press, 2002, p. 60ff (hereafter Boyle 2002).
    • Also see Shell-Duncan, Bettina and Hernlund, Ylva. "Female 'Circumcision' in Africa: Dimensions of the Practice and Debates" in Shell-Duncan and Hernlund (eds.). Female "Circumcision" in Africa. Lynne Rienner Publishers, 2000, p. 6.
21. "Annex to USAID Policy on Female Genital Mutilation/Cutting (FGM/C): Explanation of Terminology", USAID, 2000.
22. For kakia, see Kasinga, Fauziya, and Bashir, Layli Miller. Do They Hear You When You Cry. Delacorte Press, 1998, p. 2.
    • For bundu, see "Female genital mutilation in Sierra Leone", Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, accessed 9 September 2011.
    • For a discussion of bundu with local practitioners, see Van Zeller, Mariana. "Female Genital Cutting", Vanguard, Current TV, 31 January 2007.
23. Rahman and Toubia 2000, p. 4.
24. Zabus, Chantal. "Between Rites and Rights: Excision on Trial in African Women's Texts and Human Contexts," in Peter H. Marsden and Geoffrey V. Davis (eds.), Towards a Transcultural Future: Literature and Human Rights in a ' Post'-Colonial World (ASNEL Papers 8). Rodopi 2004, pp. 112–113 (hereafter Zabus 2004).
25. ^ Elmusharaf, Susan; Elhadi, Nagla; and Almroth, Lars. "Reliability of self reported form of female genital mutilation and WHO classification: cross sectional study", British Medical Journal, 332(7559), 27 June 2006.
26. ^ James, Stanlie M. "Female Genital Mutilation," in Bonnie G. Smith (ed.). The Oxford Encyclopaedia of Women in World History. Oxford University Press, 2008, pp. 259–262.
    • Also see Stanlie Myrise James, and Claire C. Robertson. Genital Cutting and Transnational Sisterhood. University of Illinois Press, 2002.
27. Fourcroy, Jean L. "Female Circumcision", American Family Physician, August 1999.
    • Fourcroy, Jean L. "The three feminine sorrows", Hospital Practice (Minneapolis), July 1998, 33(7), pp. 15–21.
28. ^ Kelly, Elizabeth, and Hillard, Paula J. Adams. "Female genital mutilation", Current Opinion in Obstetrics & Gynecology, 17(5), October 2005, pp. 490–494 (review).
29. Lewnes/UNICEF 2005, p. 16: "The mortality rate of girls and women undergoing FGM/C is not known, since few records are kept and deaths due to FGM/C are rarely reported as such. Medical records are also of limited use in determining morbidity due to FGM/C because complications resulting from the practice, including subsequent difficulties in childbirth, are often not recognised or reported as such and may be attributed to other causes. In some cases, these assigned causes may be medical in nature, but in others, they may reflect traditional beliefs or be attributed to supernatural causes. As a result, many girls who experience complications are treated with traditional medicines or cures and are not referred to health centres."
30. Van Zeller, Mariana. "Female Genital Cutting",Vanguard, Current TV, 31 January 2007, from 5:05 mins.
31. Dave, Amish J.; Sethi, Aisha; and Morrone, Aldo. "Female Genital Mutilation: What Every American Dermatologist Needs to Know", Dermatologic Clinics, 29(1), January 2011, pp. 103–109 (review).
32. Banks E. et al. "Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries", The Lancet, vol 367(9525), 3 June 2006, pp. 1835–1841.
    • For the WHO press release, see "New study shows female genital mutilation exposes women and babies to significant risk at childbirth", World Health Organization, 2 June 2006.
33. Boyle 2002, pp. 34–35.
34. Toubia, Nahid F. and Sharief, Eiman Hussein. "Female genital mutilation: Have we made progress?", International Journal of Gynecology & Obstetrics, 82(3), September 2003, pp. 251–261.
35. "Female genital mutilation", World Health Organization, February 2013: "FGM is often considered a necessary part of raising a girl properly, and a way to prepare her for adulthood and marriage.
36. ^ Izett, Susan and Toubia, Nahid. Female Genital Mutilation: An Overview. World Health Organization, 1998.
37. Martinelli, M. and Ollé-Goig, J.E. "Female genital mutilation in Djibouti, African Health Sciences, 12(4), December 2012.
38. "Changing attitudes to female circumcision", BBC News, 8 April 2002.
    • Also see Shetty, Priya. "Nahid Toubia", The Lancet, 369 (9564), 10 March 2007, p. 819.
39. Boyle 2002, p. 37.
40. Gruenbaum 2001), pp. 67–68, citing Assad 1980, p. 4.
41. Gruenbaum 2001, pp. 67–68, citing Janice Boddy, Wombs and Alien Spirits, 1989.
    • Also see "Myths and Justifications for the Perpetuation of FGM", African Women's Organization in Vienna, 2009:
    • "In some societies the clitoris is seen as a 'dangerous' organ, hence, requiring its removal. It must be removed as in Mali, Burkina Faso, and all over West Africa because it represents maleness. FGM is practiced to clearly distinguish the sex of an individual based on the belief that the foreskin of a boy makes him female and the clitoris of the female makes her a male. So in FGM practising countries the removal of the clitoris, which is believed to be male parts, makes a woman feminine. In addition, clitoris is considered to be ugly on a girl and must be removed to eliminate any indications of maleness. Some go even to the extreme by priding themselves on the degree of mutilation. According to one Sudanese woman, '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.'"
42. Gollaher, David. Circumcision: A History of the World's Most Controversial Surgery. Basic Books, 2000, p. 197.
43. "What is female genital mutilation?, Amnesty International, AI Index: ACT 77/06/97, accessed 3 September 2011.
44. "Tradition and Rights: Female Genital Cutting in West Africa", Plan International, 2005.
45. Thomas, Lynn M. "'Ngaitana (I will circumcise myself)': Lessons from Colonial Campaigns to Ban Excision in Meru, Kenya" (hereafter Thomas 2000), in Shell-Duncan and Hernlund 2000, p. 131, citing Corinne Kratz, Affecting Performance: Meaning, Movement, and Experience in Okiek Women's Initiation. Smithsonian Institution Press, 1994, p. 347.
46. ^ Thomas 2000, p. 131].
47. Van Zeller, Mariana. "Female Genital Cutting", Vanguard, Current TV, 31 January 2007, from 5:25 mins.
48. Gruenbaum, Ellen. The Female Circumcision Controversy: An Anthropological Perspective. University of Pennsylvania Press, 2001 (hereafter Gruenbaum 2001), pp. 63–66.
    • Also see Wakabi, Wairagala. "Africa battles to make female genital mutilation history", The Lancet, 369 (9567), 31 March 2007, pp. 1069–1070.
    • Mustafa, Asim Zaki. "Female circumcision and infibulation in the Sudan", Journal of Obstetrics and Gynaecology, 73(2), 1966 (pp. 302–306), p. 302.
49. "Circumcision", in R.J. Zwi Werblowsky, R. J. and Geoffrey Wigoder (eds.). The Oxford Dictionary of the Jewish Religion. Oxford University Press, 1997.
50. Momoh 2005, p. 2.
51. Lewnes/UNICEF 2005, p. 7: "The large majority of girls and women are cut by a traditional practitioner, a category which includes local specialists (cutters or exciseuses), traditional birth attendants and, generally, older members of the community, usually women. This is true for over 80 percent of the girls who undergo the practice in Benin, Burkina Faso, Côte d’Ivoire, Eritrea, Ethiopia, Guinea, Mali, Niger, Tanzania and Yemen. In most countries, medical personnel, including doctors, nurses and certified midwives, are not widely involved in the practice. Egypt offers a clear exception: in 2000, it was estimated that in 61 per cent of cases, FGM/C had been carried out by medical personnel. The share of FGM/C carried out by medical personnel has also been found to be relatively high in Sudan (36 per cent) and Kenya (34 per cent)."
52. ^ Elchalal, Uriel et al'. "Ritualistic Female Genital Mutilation: Current Status and Future Outlook", Obstetrical & Gynecological Survey, 52(10), October 1997, pp. 643–651.
    • For a report of this procedure, see Black, Donald Campbell. On the Functional Diseases of the Renal, Urinary and Reproductive Organs. Lindsay & Blakiston, 1872, pp. 127–129.
53. ^ Nussbaum 1999, p. 120.
54. Sharif, Khadijah F. "Female Genital Mutilation," in Nadine Taub, Beth Anne Wolfson, and Carla M. Palumbo (eds.). The Law of Sex Discrimination. Cengage Learning, 2010, p. 440: "The girl's legs are bound together at the ankle, above the knees, and around the thighs for approximately fifteen to forty days to limit movement and to facilitate proper healing. To ensure tightness of the hole, a thorn is inserted into the vagina, so that when the tissue heals, only this opening remains."
55. Elchalal, Uriel et al. "Ritualistic Female Genital Mutilation: Current Status and Future Outlook", Obstetrical & Gynecological Survey, 52(10), October 1997, pp. 643–651.
    • For an opening the size of a matchstick, see "Female Genital Mutilation (FGM) or Female Genital Cutting (FGC): Individual Country Reports", U.S. Department of State, 1 June 2001, p. 14: "Type III is the excision (removal) of part or all of the external genitalia (clitoris, labia minora and labia majora) and stitching or narrowing of the vaginal opening leaving a very small opening, about the diameter of a matchstick, to allow for the flow of urine and menstrual blood. The girl or woman’s legs are generally bound together from the hip to the ankle so she remains immobile for approximately 40 days to allow for the formation of scar tissue."
    • For twigs or rock salt being inserted into the wound, see Momoh 2005, p. 22: "Twigs or rock salt may be inserted into the vagina to maintain a small opening to allow urine and menstrual fluid to pass through and the whole area may be covered with soil and bark at the end of the procedure to promote healing."
    • For a 1977 study and a description of Type III, see Pieters, Guy and Lowenfels, Albert B. "Infibulation in the Horn of Africa", New York State Journal of Medicine, 77(6), April 1977, pp. 729–731.
    • For another description of Type III from the 1970s, see Gollaher, David. "Female Circumcision," Circumcision: A History of the World's Most Controversial Surgery. Basic Books, 2001 (pp. 187–207), p. 191:

    • A French doctor, Jacques Lantier, who attended an FGM procedure in Somalia in the 1970s described how the inner and outer labia were separated and attached to each thigh using large thorns. "With her kitchen knife the woman then pierces and slices open the hood of the clitoris and then begins to cut it out. While another woman wipes off the blood with a rag, the operator digs with her fingernail a hole the length of the clitoris to detach and pull out that organ. The little girls screams in extreme pain, but no one pays the slightest attention."

      After removing the clitoris with the knife, the woman "lifts up the skin that is left with her thumb and index finger to remove the remaining flesh. She then digs a deep hole amidst the gushing blood. The neighbor women who take part in the operation then plunge their fingers into the bloody hole to verify that every remnant of the clitoris is removed."

56. Momoh 2005, pp. 6–7.
57. Momoh 2005, pp. 24–25.
58. Lightfoot-Klein, Hanny. "The Sexual Experience and Marital Adjustment of Genitally Circumcised and Infibulated Females in The Sudan", The Journal of Sex Research, 26(3), 1989, pp. 375–392 (also available here.
59. Izett and Toubia (WHO), 1998.
60. Bergrren, Vanja, et al. "Being Victims or Beneficiaries? Perspectives on Female Genital Cutting and Reinfibulation in Sudan", African Journal of Reproductive Health, 10(2), August 2006.
    • Also see Bergrren, Vanja, et al. "An explorative study of Sudanese midwives’ motives, perceptions and experiences of re-infibulation after birth", Midwifery, 20(4), December 2004, pp. 299–311.
    • Serour G.I. "The issue of reinfibulation", International Journal of Gynaecology and Obstretrics, 109(2), May 2010, pp. 93–96.
61. Nour N.M.; Michaels K.B.; and Bryant A.E. "Defibulation to Treat Female Genital Cutting: Effect on Symptoms and Sexual Function", Obstetrics & Gynecology, 108(1), July 2006, pp. 55–60.
62. Conant, Eve. "The Kindest Cut", Newsweek, 27 October 2009.
    • Foldes, Pierre. "Surgical Repair of the Clitoris after Ritual Genital Mutilation: Results of 453 Cases", WAS Visual, accessed 17 September 2011.
63. "Prevalence of Female Genital Mutilation (FGM) in Africa", Afrol News.
64. Caldwell, John C.; Orubuloye, I.O.; and Caldwell, Pat. "Female Genital Mutilation: Conditions of Decline", Population Research and Policy Review, 19(3), June 2000 (pp. 233–254), p. 235.
65. "An update on WHO’s work on female genital mutilation (FGM)", World Health Organization, 2011, p. 2: "Most women who have experienced FGM live in one of the 28 countries in Africa and the Middle East – nearly half of them in just two countries: Egypt and Ethiopia."
66. ^ Rahman and Toubia 2000, pp. 9–10.
67. Natsoulas, Theodore."The Politicization of the Ban of Female Circumcision and the Rise of the Independent School Movement in Kenya: The KCA, the Missions and Government, 1929–1932", Journal of African Studies, 33(2), April 1998, pp. 137–158.
    • Also see Strayer, Robert and Murray, Jocelyn. "The CMS and Female Circumcision," in Robert Strayer. The Making of Missionary Communities in East Africa. Heinemann Educational Books, 1978, p. 36ff.
68. ^ Abusharaf, Rogaia Mustafa. "Revisiting Feminist Discourses on Inbulation: The Hosken Report," in Shell-Duncan and Hernlund 2000, pp. 160–163.
69. Thomas 2000, p. 132.
70. Mufaka, Kenneth. "Scottish Missionaries and the Circumcision Controversy in Kenya, 1900–1960", International Review of Scottish Studies, vol 28, 2003.
71. Thomas 2000, p. 136.
72. Birch, Nicholas. "An End to Female Genital Cutting?", Time magazine, 4 January 2008.
73. Thomas 2000, pp. 129–130
    • Also see Thomas, Lynn M. "'Ngaitana (I will circumcise myself)': The Gender and Generational Politics of the 1956 Ban on Clitoridectomy in Meru, Kenya", Gender and History, 8(3), November 1996, pp. 338–363.
74. Bennett, Jane. "Subversion and resistance: activist initiatives," in Tamale (ed.) 2011, pp. 89–90.
75. ^ Thomas 2000, p. 130.
76. "Female Genital Mutilation (FGM) or Female Genital Cutting (FGC): Individual Country Reports", U.S. Department of State, 1 June 2001.
77. Momoh 2005,p. 15.
78. Michael, Maggie."Egypt Officials Ban Female Circumcision", The Associated Press, 29 June 2007.
    • Kandela, Peter. "Egypt sees U turn on female circumcision",British Medical Journal, 310(6971), 1995.
    • For the Al-Azhar statement, see "Fresh progress toward the elimination of female genital mutilation and cutting in Egypt", UNICEF, 2 July 2007.
79. "Mauritania fatwa bans female genital mutilation", BBC News, 18 January 2010.
80. Feldman-Jacobs, Charlotte. "Commemorating International Day of Zero Tolerance to Female Genital Mutilation", Population Reference Bureau, February 2009.
81. Tamale in Tamale (ed.) 2011, pp. 19–20.
82. Lewnes/UNICEF 2005, p. 4: "Beyond economic factors, migratory patterns have frequently reflected links established in the colonial past. For instance, citizens from Benin, Chad, Guinea, Mali, Niger and Senegal have often chosen France as their destination, while many Kenyan, Nigerian and Ugandan citizens have migrated to the United Kingdom.

    "In the 1970s, war, civil unrest and drought in a number of African states, including Eritrea, Ethiopia and Somalia, resulted in an influx of refugees to Western Europe, where some countries, such as Norway and Sweden, had been relatively unaffected by migration up to that point. Beyond Western Europe, Canada and the USA in North America, and Australia and New Zealand in Australasia also host women and children who have been subjected to FGM/C, and are home to others who are at risk of undergoing this procedure."

83. Essen, Birgitta and Johnsdottir, Sara."Female Genital Mutilation in the West: Traditional Circumcision versus Genital Cosmetic Surgery", Acta Obstetricia Gynecologica Scandinavica, vol 28, 2004, pp. 611–613. PMID 15225183.
84. For New Zealand and Australia, see Rahman and Toubia 2000, pp. 102–103, 191.
    • For New Zealand, also see "Section 204A - Female genital mutilation - Crimes Act 1961", New Zealand Parliamentary Counsel Office, accessed 12 October 2011.
    • For Canada, see "Family Violence: Department of Justice Canada Overview paper", Department of Justice, 31 July 2007, footnote 4.
    • For the European Union, see Rowling, Megan. "France reduces genital cutting with prevention, prosecutions - lawyer", Thomson Reuters Foundation, 27 September 2012 (hereafter Rowling 2012).
85. Cullen-DuPont, Kathryn. "Female genital mutilation,"Encyclopedia of Women's History in America. Da Capo Press, 1998, p. 85.
86. Dugger, Celia W."June 9-15; Asylum From Mutilation",The New York Times, 16 June 1996.
    • "In re Fauziya KASINGA, file A73 476 695, U.S. Department of Justice, Executive Office for Immigration Review, decided 13 June 1996.
    • Dugger, Celia W. "Woman's Plea for Asylum Puts Tribal Ritual on Trial", The New York Times, 15 April 1996.
87. Zabus 2004, p. 110.
88. Hassan, Yasmeen. "As Global Consensus Accelerates, Obama Strengthens Federal Law Protecting Girls in the Fight Against Female Genital Mutilation",The Huffington Post, 3 January 2013.
    • For the legal situation in the US as of 2008, see Ross, Susan Deller (ed.). Women's Human Rights: The international and Comparative Law Casebook. Vantage Press, 2008, p. 509ff.
89. "Man gets 10-year sentence for circumcision of 2-year-old daughter", Associated Press, 1 November 2006.
90. McVeigh, Tracy and Sutton, Tara. "British girls undergo horror of genital mutilation despite tough laws", The Guardian, 25 July 2010.
91. Kerbaj, Richard."Thousands of girls mutilated in Britain",The Times, 16 March 2009.
92. Torjesen, Ingrid. "First UK prosecution for female genital mutilation moves a step closer", British Medical Journal, 8 May 2013.
93. Rowling 2012.
94. Seligman, Charles G."Aspects of the Hamitic problems in the Anglo-Egyptian Sudan", The Journal of the Royal Anthropological Institute of Great Britain and Ireland, 1913, 40(3), (pp. 593–705), pp. 612, 639–640.
    • For a discussion of Seligman, see Hicks, Esther K. Infibulation: Female Mutilation in Islamic Northeastern Africa. Transaction Publishers, 1996, pp. 19ff and 209ff.
95. Knight, Mary. "Curing Cut or Ritual Mutilation?: Some Remarks on the Practice of Female and Male Circumcision in Graeco-Roman Egypt", Isis, 92(2), June 2001 (pp. 317–338), (hereafter Knight 2001), p. 318:
    • "That custom is excision of the clitoris and other external female genitalia, sometimes called female circumcision but now usually referred to in Egypt as female genital mutilation (FGM); the first extant literary mention of it is by the Greek geographer Strabo, who visited Egypt in about 25 BCE: 'This is one of the customs most zealously pursued by them : to raise every child that is born and to circumcise the males and excise the females'" (citing Strabo,Geographika, 17.2.5).
    • Strabo, Geography of Strabo, Book VII, chapter 2, 17.2.5, wrote:

    • "One of the customs most zealously observed among the Aegyptians is this, that they rear every child that is born, and circumcise the males, and excise the females, as is also customary among the Jews, who are also Aegyptians in origin, as I have already stated in my account of them."

    • Strabo also wrote, Geography of Strabo, Book XVI, chapter 4, 16.4.9:

    • "And then to the Harbour of Antiphilus, and, above this, to the Creophagi , of whom the males have their sexual glands mutilated and the women are excised in the Jewish fashion."
    • A different translation here reads: "Then follows the harbour of Antiphilus, and above this a tribe, the Creophagi, deprived of the prepuce, and the women are excised after the Jewish custom."

    • Jacob Neusner writes that Strabo was confused about Jewish custom. He also writes: "the Greek verbπεριτέμνειν 'to cut around/off,' denoted not only circumcision but could be used of any mutilation of body parts, such as the severing of a nose or ears; in Herodotus it is associated with various barbarian practices." See Neusner, Approaches to Ancient Judaism, Volume 4, Scholars Press, 1993, p. 148.
    • Also see Bryk, Felix. Circumcision in Man and Woman: Its History, Psychology, and Ethnology. The Minerva Group, Inc., 2001, pp. 45–46.
96. Knight 2001, p. 330.
97. Knight 2001, p. 331, citing G. Elliot Smith, A Contribution to the Study of Mummification in Egypt, 1906, p. 30.
    • Knight also quotes Marc Armand Ruffer (1859–1917), Studies in the Paleopathology of Egypt, University of Chicago Press, 1921, p. 171: "the bodies are in such a state that it would often be difficult to state with certainty whether such an operation had been done." She adds: "In light of the fact that only rarely have scientific researchers autopsying mummies specifically looked for the presence or absence of FGM, conclusive remarks about the prevalence of the practice must await a detailed study of a large cohort of female mummies." See Knight 2001, p. 331.
98. Knight 2001, p. 333.
99. Knight 2001, p. 326: "Extant fragments from a fifth-century BCE history of Lydia by Xanthos of Lydia, a contemporary of Herodotus, say: 'The Lydians arrived at such a state of delicacy that they were even the first to "castrate" their women.'" Lydia wrote that the purpose of the "castration," which is not described, was to keep women youthful, perhaps in the sense of allowing the Lydian king to have intercourse with them without pregnancy. Knight concludes that "castration" is therefore probably not a reference to FGM, but may have been a reference to some form of sterilization.
100. Mackie 1996, p. 1003 (an open access edition is available here), citing João dos Santos, Ethiopia Oriental, 1609.
     • Note: Gerry Mackie is Associate Professor of Political Science at the University of California, San Diego, as well as co-director of the Center on Global Justice, and of the UNICEF Learning Program on Changing Social Conventions and Social Norms; see here.
101. Mackie 1996, pp. 1008–1009.
102. Rodriguez, Sarah W. "Rethinking the history of female circumcision and clitoridectomy: American medicine and female sexuality in the late nineteenth century", Journal of the History of Medicine and Allied Sciences. 63(3), July 2008, pp. 323–347.
103. Allen, Peter Lewis. The Wages of Sin: Sex and Disease, Past and Present. University of Chicago Press, 2000, p. 106.
     • For the obituary, see J.F.C. "Isaac Baker Brown, F.R.C.S.", Medical Times and Gazette, 8 February 1873.
     • Also see Brown, Isaac Baker. On the Curability of Certain Forms of Insanity, Epilepsy, Catalepsy, and Hysteria in Females. Robert Hardwicke, 1866.

Further reading

Resources

• Campaign Against Female Genital Mutilation, International Campaign Against FGM.
• End FGM campaign, End FGM European campaign run by Amnesty International.
• FORWARD, The Foundation for Women's Health, Research and Development.
• "Hospitals and Clinics in the UK offering Specialist FGM (Female Genital Mutilation) Services", FORWARD.

Books

• Abdalla, Raqiya Haji Dualeh. Sisters in Affliction: Circumcision and Infibulation of Women in Africa. Zed Books, 1982.
• Aldeeb, Sami. Male & Female circumcision: Among Jews, Christians and Muslims. Shangri-La Publications, 2001.
• Dettwyler, Katherine A. Dancing Skeletons: Life and Death in West Africa. Waveland Press, 1994.
• Dorkenoo, Efua. Cutting the Rose: Female Genital Mutilation. Minority Rights Publications, Harry Ransom Humanities Research Center, 1996.
• Mernissi, Fatima. Beyond the Veil: Male-Female Dynamics in a Modern Muslim Society. Indiana University Press, 1987 .
• Sanderson, Lilian Passmore. Against the Mutilation of Women. Ithaca Press, 1981.
• Skaine, Rosemarie. Female Genital Mutilation. McFarland & Company, 2005.
• Walker, Alice. Possessing the Secret of Joy. New Press, 1993 (novel).
• Zabus, Chantal. Between Rites and Rights: Excision on Trial in African Women's Texts and Human Contexts. Stanford University Press, 2007.

Personal stories

• Ali, Ayaan Hirsi. Infidel: My Life. Simon & Schuster, 2007: Ali experiences FGM at the hands of her grandmother.
• Dirie, Waris. Desert Flower. Harper Perennial, 1999: autobiographical novel about Dirie's childhood and genital mutilation.
• Dirie, Waris. Desert Dawn. Little, Brown, 2003: how Dirie became a UN Special Ambassador for FGM.
• Dirie, Waris. Desert Children. Virago, 2007: FGM in Europe.
• El Saadawi, Nawal. Woman at Point Zero. Zed Books, 1975.
• Williams-Garcia, Rita. No Laughter Here. HarperCollins, 2004: a ten-year-old Nigerian girl undergoes FGM while on vacation in her homeland.

Articles

• Abusharaf, Rogaia Mustafa. "Virtuous Cuts: Female Genital Circumcision in an African Ontology", Differences: A Journal of Feminist Cultural Studies, vol 12, 2001, pp. 112–140.
• Althaus, Francis A. "Female Circumcision: Rite of Passage Or Violation of Rights?", International Family Planning Perspectives, 23(3), September 1997.
• Boddy, Janice. "Womb as oasis: The symbolic context of Pharaonic circumcision in rural Northerm Sudan", American Ethnologist, 9(4), November 1982.
• Chase, Cheryl. "'Cultural practice' or 'Reconstructive Surgery'? U.S. Genital Cutting, the Intersex Movement, and Medical Double Standards", in Stanlie M. James and Claire C. Robertson (eds.). Genital Cutting and Transnational Sisterhood. University of Illinois Press, 2002.
• Darugar, Maliha A; Harris, Rebecca M; and Frader, Joel E. "Consent and cultural conflicts: ethical issues in pediatric anesthesiologists' participation in female genital cutting", in Gail A. Van Norman et al. Clinical Ethics in Anesthesiology: A Case-Based Textbook. Cambridge University Press, 2010.
• Ehrenreich, Nancy and Barr, Mark. "Intersex Surgery, Female Genital Cutting, and the Selective Condemnation of 'Cultural Practices'", Harvard Civil Rights-Civil Liberties Law Review, 40(1), 2005, pp. 71–140.
• Ferguson, Ian and Ellis, Pamela. "Female Genital Mutilation: a Review of the Current Literature", Research Section, Department of Justice, Canada, 1995.
• Haworth, Abigail. "The day I saw 248 girls suffering genital mutilation", The Guardian, 18 November 2012.
• Kouba, Leonard and Muascher, Judith. "Female Circumcision in Africa: An Overview", African Studies Review, 28(1), March 1985, pp. 95–110.
• Oguntoye, Susana. "'FGM is with us Everyday': Women and Girls Speak Out about Female Genital Mutilation in the UK", World Academy of Science and Engineering, vol 54, 2009.
• Population Reference Bureau. "Female Genital Mutilation/Cutting: Data and Trends", 2008.
• Shell-Duncan, Bettina. "The medicalization of female "circumcision": harm reduction or promotion of a dangerous practice?, Social Science & Medicine, 52(7), 2001, pp. 1013–1028.
• UNICEF. "Coordinated Strategy to Abandon Female Genital Mutilation/Cutting in One Generation".
• Westley, David M. "Female circumcision and infibulation in Africa", Electronic Journal of Africana Bibliography, 4, 1999 (contains an extensive bibliography).

Films

• Brendecke, Dagmar and Müller-Belecke, Anke. Schnitt ins Leben – Afrikanerinnen bekämpfen ein Ritual. Germany, 2000 (documentary).
• Dacosse, Marc and Eric Dagostino, Eric. L’Appel de Diégoune (Walking the Path of Unity). Tostan, France, 2009; link courtesy of Tostan International, YouTube.
• Eran, Doron. God's Sandbox. Israel, 2006: An Israeli girl joins a Muslim tribe and is forced to undergo FGM.
• Hormann, Sherry. Desert Flower. 2009: Based on Waris Dirie's book, Desert Flower.
• Johnson, Kirsten and Pimsleur, Julia. Bintou in Paris. France, 1995 (documentary).
• Kouros, Alex. Kokonainen. Finland, 2005: won the 2005 New York Short Film Festival Jury Award for Best Screenplay.
• Longinotto, Kim. The Day I Will Never Forget. UK, 2002.
• Maldonado, Fabiola. Maimouna – La vie devant moi. Germany, 2007 (documentary).
• Pomerance, Erica. Dabla! Excision. Canada, 2003: Follows the growing movement across Africa to stop FGM.
• Sembène, Ousmane. Moolaadé. Senegal, France, Burkina Faso, Cameroon, Morocco, Tunisia, 2004.
• Sissoko, Cheick Oumar. Finzan. Mali, 1989: Two women rebel against the traditions of a village society.
• Wilkins, Oliver. Short film on FGM in Minya, Egypt, vimeo.com.

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