Female Genital Mutilation
Types of Female Genital Mutilation/Cutting Female genital mutilation/cutting (FGM/C) refers to a variety of operations involving partial or total removal of female external genitalia. The female external genital organ consists of the vulva, which is comprised of the labia majora, labia minora, and the clitoris covered by its hood in front of the urinary and vaginal openings. In 2007, the World Health Organization classified FGM/C into four broad categories:
Type 1 or Clitoridectomy: Partial or total removal of the clitoris and/or the clitoral hood.
Type 2 or Excision: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora.
Type 3 or Infibulation: Narrowing of the vaginal orifice with creation of a covering seal by cutting and placing together the labia minora and/or the labia majora, with or without excision of the clitoris.
Type 4 or Unclassified: All other harmful procedures to the female genitalia for nonmedical purposes, for example, pricking, piercing, incising, scraping, and cauterization.
According to the US Department of State, FGM Type I and II are practiced in Uganda. According to the World Health Organization, 0.6% is the estimated prevalence of FGM in girls and women aged 15-49 years in Uganda. According to the US Department of State, the prevalence of FGM in Uganda is less than 5% of the female population. It was practiced by the Sabiny ethnic group in rural Kapchorwa District and the Pokot ethnic group along the northeastern border with Keny. An article dated 12 December 2008 in The Monitor reports that “FGM is mainly carried out among the Sabiny tribe in Kapchorwa and Bukwo districts, and the Pokot in Nakapiripirit District. Other districts where groups that carry out the practice have settled include Isingiro, Kamuli, Kamwenge and Bugiri.” An article dated 14 December 2008 in New Vision reports that FGM “is most prevalent in Kapchorwa, Bukwo and Karamoja. Studies, however, indicate that the practice also exists in Kamuli, Kamwenge, Isingiro and Masindi” (Naturinda, Sheila 2008, ‘Female cut could earn culprits 7 years in jail’, The Monitor, 12 December http://www.monitor.co.ug/artman/publish/news/Female_cut_could_earn_culprits_7_years_in_jail_76710.shtml – Accessed 25 February 2009 ‘Uganda: Criminalise Female Genital Mutilation’ 2008, New Vision, 14 December, allAfrica.com website http://allafrica.com/ February 2009 and US Department of State 2009, 2008 Country Reports on Human Rights Practices – Uganda, 25 February.
An article dated 10 June 2008 in The Monitor reports that “Reach [Reproductive Educative and Community Health] was established in Kapchorwa in 1996 to improve the reproductive health conditions and discard the harmful practice of FGM and 12 years down the road, the practice has dropped to about 36 percent.” An article dated 30 June 2008 in New Vision reports that REACH programme statistics show that “6198 women underwent genital mutilation between 1990 and 2004 in Kapchorwa” (Mafabi, David 2008, ‘Uganda: Resisting the Cut’, The Monitor, 10 June, allAfrica.com website http://allafrica.com/ ; and Ssenkaaba, Stephen 2008, ‘Uganda: Genital Mutilation. Women Grapple With a Deadly Tradition’, New Vision, 30 June, allAfrica.com website http://allafrica.com/. 2008 An article dated 6 January 2009 in New Vision reports that “some 500 girls were circumcised in Sebei region over the Christmas period ” (‘FGM can be defeated by joint effort’ 2009, New Vision, 6 January http://www.newvision.co.ug/D/8/14/667148 . An article dated 5 February 2009 in New Vision reports that during the 2008 season, “over 500 girls were circumcised” in Kapchorwa district. The article also reports that in 2008 “about 900 girls underwent the ritual in Sebei”. The article provides the following explanation on the increase in the number of female circumcisions performed: After realising the ills of FGM in the 1990s, many educated Sabiny joined the international community to fight the practice that was not only causing grave harm to the health of the girls, but also hindered their education. A community-based non-governmental organisation, Reproductive Educative and Community Health (REACH) spearheaded the advocacy and health education campaigns against FGM. Dr. Steven Chebrot, the former area MP and Jane Francis Kuka, former Woman MP, took part. Indeed, the campaign had a big impact. At least half of the girls that were to undergo FGM denounced it. With the help of the Italian Mission under a lady called Sister Isabella, girls were given scholarships to study at Gamatui Girls’ School in Kapchorwa. As a part-time teacher at Gamatui Girls’ School, I saw over 100 girls denounce FGM every week and embrace education. I learnt that due to poverty, parents were circumcising their girls to marry them off to get bride price. Parents who had wanted their girls to get free education would threaten to circumcise them. And when the mission heard this, they would offer the girls scholarships. However, when the politicians saw scholarships ‘flying’ to these girls, they looked for ways of making their relatives benefit, even when they were not eligible. This is how the FGM campaign was bogged down. The children of the poor stopped benefiting and the scholarships went to the rich. The Sabiny started hating politicians for “influencing who gets scholarships.” …It is against this background that the people of Sebei stopped fighting FGM. When the sponsors of the girls saw the programme being washed down by the politicians, they withdrew their support. It is for this reason that FGM emerged once again. Several attempts by REACH to sensitise the people hit a snag because, unlike the previous programme that used to come with scholarships and benefits like heifers for the girls and the ‘surgeons’, this one is only based on messages, which messages, the community says “are not edible” (Womakuyu, Frederick 2009, ‘Only educating girls can help eradicate female circumcision’, New Vision, 5 February http://www.newvision.co.ug/D/8/459/670476 . An article dated 31 December 2008 in New Vision reports that health experts in Bukwo, say that female circumcision “has increased by almost 90% this year from 40% in 2006.” Reach started a sensitisation programme in Bukwo in 2006:
The elders say REACH had promised to set up a girls’ school in the district, sponsor the education of the girls and give the ‘surgeons’ heifers, but they did not. “We saw no need to stop the practice because many girls come from poor families and cannot afford fees. So the only option they have is to get circumcised and get married,” an elder said. Sunday Kokop, a ‘surgeon’ also said politicians from the area are promoting the practice. “Many people in the area support the practice, so politicians do not want to talk against it for fear of losing support,” she adds. Kiprotich [District Speaker] adds that the practice is widespread in neighbouring Kenya, which has made the people of Bukwo to continue with it (Womakuyu, Frederick 2008, ‘Uganda: Sebei Lose Battle Against Female Circumcision’, New Vision, 31 December, allAfrica.com website http://allafrica.com/s. According to Sara Horsfall, Texas Wesleyan University and Rebecca Salonen, Godparents Association Inc, “Among the Sabiny, the type of FGM practiced is excision, where the clitoris and labia minora are cut away. “Spontaneous infibulation,” the knitting together of the wound through scar tissue, often occurs, but no stitching is traditionally involved to close the wound. It is considered the female parallel to male circumcision.” An article dated 22 December 2008 in New Vision reports in “Kapchorwa and Bukwa in Uganda, the type of FGM practiced is Type 2” (Horsfall, Sara & Salonen, Rebecca 2000, Female Genital Mutilation and Associated Gender and Political Issues Among the Sabiny of Uganda, March, Stop FGM website http://www.stopfgm.org/stopfgm/doc/EN/90.pdf.
Horsfall and Salonen, in their March 2000 report entitled Female Genital Mutilation and Associated Gender and Political Issues Among the Sabiny of Uganda provide the following information on the festivities associated with and the reasons for female circumcision: Circumcision season falls during the November/December school holidays of even-numbered years for both boys and girls, though some are cut in the off-years if they wish to marry. Girls who avoid cutting usually relent under heavy social pressure and intimidation from relative and neighbors despite the promise of lifelong pain and the possibility of death (Kuka 1998). Even a woman who manages to get married prior to cutting is likely to be pressured into it after marriage by her in-laws. A three-week festival accompanies circumcision and cutting when girls of about 15 years old and boys of 17 or 18 from throughout the region are initiated. It is a big occasion for everyone. Once the season is declared open by the elders, for about three weeks male circumcision candidates run through the villages of the District, collecting gifts and congratulations from friends and relatives, who often join in the run to the next village. During this time, a boy collects the foundation for the bride price to be offered for a newly circumcised girl to be his wife. Female cutting candidates do not tour the district but remain in the family homestead, where they are prepared for what is to come. There is feasting and merry making. Local maize beer is brewed for the occasion and sipped by adults gathered around a pot using special three-or four foot long straws. Beer drinking is so important to the festivities that ceremonies were traditionally timed to coincide with large maize harvests. On the night before the cutting is to take place, age cohorts and school mates gather together, separated by gender. Girls dance all night and the accompanying singing and drumming resounds throughout the area. Around dawn the next morning, the “secrets” and history of the culture are imparted to the initiation candidates. Young men and women are exhorted never to reveal their tribal secrets to uncircumcised Sabiny or to outsiders. Then comes the cutting and circumcision, performed in separate places. (Traditionally men could not be present during the ceremonies for girls, but this appears to have changed somewhat in recent years.) Sabiny girls are expected to be brave during the procedure. They are not restrained. They lie down in turn on the cutting mat with their arms extended over their heads. After pulling up their skirts and arranging their legs to allow the procedure they do not blink an eye in reaction to the cuts. After the excision, the girls are allowed to recover without much aftercare. The wound is traditionally treated with cow’s urine. Cutting and circumcision not only make the passage into adulthood, they mark the beginning of community and civic responsibility. Prior to the cutting, a girl is not allowed to speak in public, in front of those who have already been circumcised. She is considered “only a girl,” and may not even undertake important women’s tasks such as milking cows and drawing grain from the communal granary. However, after she is cut she is accepted as a woman, with all the prerogatives granted by the Sabiny, including full rights to leadership as an elder among the tribe (Horsfall, Sara & Salonen, Rebecca 2000, Female Genital Mutilation and Associated Gender and Political Issues Among the Sabiny of Uganda, March, Stop FGM website http://www.stopfgm.org/stopfgm/doc/EN/90.pdf – Accessed 24 May – Attachment 19). An article dated 13 October 2008 in New Vision, Sam Anguria, member of the Gulu Gender-Based Violence Group provides useful information on the cultural significance of FGM to the Sabiny: The Sabinyattach a lot of importance to female genital mutilation (FGM), which explains why it has existed for centuries.
An estimated 100 million to 140 million girls and women worldwide have undergone female genital mutilation/ cutting (FGM/C) and more than 3 million girls are at risk for cutting each year on the African continent alone. FGM/C is generally performed on girls between ages 4 and 12, although it is practiced in some cultures as early as a few days after birth or as late as just prior to marriage. Typically, traditional excisors have carried out the procedure, but recently a discouraging trend has emerged in some countries where medical professionals are increasingly performing the procedure. FGM/C poses serious physical and mental health risks for women and young girls, especially for women who have undergone extreme forms of the procedure. According to a 2006 WHO study, FGM/C can be linked to increased complications in childbirth and even maternal deaths. Other side effects include severe pain, haemorrhage, tetanus, infection, infertility, cysts and abscesses, urinary incontinence, and psychological and sexual problems. FGM/C is practiced in at least 28 countries in Africa and a few others in Asia and the Middle East. FGM/C is practiced at all educational levels and in all social classes and occurs among many religious groups (Muslims, Christians, and animists), although no religion mandates it. Prevalence rates vary significantly from country to country (from nearly 98 percent in Somalia to than 1 percent in Uganda) and even within countries.
A mother’s story: Challenges faced by those who begin the process of change Khadija is a devout Ansar Sunna Muslim from the Beni Amer tribal group in Eastern Sudan. She lives with her extended family. When she leaves the house, she covers herself in a black abaya (garment) and face veil to be properly modest. As a girl, she underwent infibulations, known in Sudan as “paranoiac” cutting, according to Beni Amer tradition. Now she has a six-year-old daughter who has not yet been cut. Khadija attended a program about harmful traditional practices, where she learned about the health complications associated with FGM/C. Along with other women, she registered her daughter with the group of uncircumcised girls. Yet Khadija is troubled. Although she doesn’t want her daughter to suffer from the health complications she heard about, she knows that men favour the practice for religious reasons. She also expects that her mother-in-law will have something to say about it. “If I don’t cut her, there won’t be anyone to marry her,” says Khadija. “I wish I didn’t have daughters, because I am so about them.”
FGM/C irreversibly compromises a girl or woman’s physical integrity. The damage caused by this procedure can pose a serious risk to her health and wellbeing. In extreme cases, FGM/C can also violate a girl or woman’s right to life. Fatalities are often due to severe and uncontrolled bleeding or to infection after the procedure. Moreover, FGM/C may be a contributory or causal factor in maternal death. 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.
Until recently, information on the physical complications associated with FGM/C has tended to be based on case history reports from hospitals. Moreover, there have been few comparisons with uncut women to establish the relative frequency of these complications. In recognition of the need for better data, WHO has now developed research protocols on FGM/C with a network of collaborating research institutions as well as biomedical and social science researchers with linkages to communities concerned. The specific impact of FGM/C on the health of a girl or woman depends on a number of factors, including the extent and type of the cutting, the skill of the operator, the cleanliness of the tools and of the environment, and the physical condition of the girl or woman. Severe pain and bleeding are the most common immediate consequences of all forms of FGM/C. As the great majority of procedures are carried out without anaesthetic, the pain and trauma experienced can leave a girl in a state of medical shock. In some cases, bleeding can be protracted and girls may be left with long-term anaemia. Infection is another common consequence, particularly when the procedure is carried out in unhygienic conditions or using unsterilized instruments. The type and degree of infections vary widely and include potentially fatal septicaemia and tetanus. Sometimes the risk of infection is increased by traditional practices, such as binding of the legs after infibulations or applying traditional medicines to the wound. Urine retention is another frequent complication, especially when skin is stitched over the urethra. All these elements may contribute to the wound failing to heal quickly, as may other factors affecting a girl’s general health, including anaemia and malnutrition. FGM/C can result in long-term physical effects. Slow or incomplete healing leaves abscesses, painful cysts and thick, raised scars called keloids. These in turn can cause problems in later stages, including in pregnancy and childbirth. Deinfibulation the procedure to re-open the orifice after it has been stitched or narrowed and reinfibulation to re-stitch the vagina may be performed at each birth. Both procedures seriously compromise the health of women. FGM/C also jeopardises the health and survival of the children of women who have undergone the procedure. A recently completed WHO study investigated the effects of FGM/C on a range of maternal and infant outcomes during and immediately following delivery. These include caesarean section, length of labour, postpartum haemorrhage, perineal injury, low birth weight, low Agpar score and perinatal death. Initial analysis of the data from some 28,000 women in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan indicates a relationship between some maternal and infant outcomes and FGM/C, especially in its more severe forms. Concern has been raised at the possible link between FGM/C and HIV transmission. To date, no concrete evidence for this link exists, and rates of HIV infection in Africa are generally lower in the 28 countries where FGM/C is practiced. This may, however, be due to factors that prevail over the additional risk factor of FGM/C, including cultural and religious attitudes to sexual life. A community-based study in rural Gambia in 1999 identified a significantly higher prevalence of herpes simplex virus 2 among women who had been subjected to FGM/C, a finding which suggests that these women may also be at increased risk of HIV infection.
Concrete field experience, together with insights from academic theory and lessons learned from the experience of foot binding in China suggest that six key elements can contribute to transforming the social convention of cutting girls and encourage the rapid and mass abandonment of the practice. 1. A non-coercive and non-judgmental approach whose primary focus is the fulfilment of human rights and the empowerment of girls and women. Communities tend to raise the issue of FGM/C when they increase their awareness and understanding of human rights and make progress towards the realisation of those they consider to be of immediate concern, such as health and education. Despite taboos regarding the discussion of FGM/C, the issue emerges because group members are aware that the practice causes harm. Community discussion and debate contribute to a new understanding that girls would be better off if everyone abandoned the practice. 2. Awareness on the part of a community of the harm caused by the practice. Through non-judgmental, non-directive public discussion and reflection, the costs of FGM/C tend to become more evident as women and men share their experiences and those of their daughters. 3. The decision to abandon the practice as a collective choice of a group that intermarries or is closely connected in other ways. FGM/C is a community practice and, consequently, is most effectively given up by the community acting together rather than by individuals acting on their own. Successful transformation of the social convention ultimately rests with the ability of members of the group to organize and take collective action. 4. An explicit, public affirmation on the part of communities of their collective commitment to abandon FGM/C. It is necessary, but not sufficient, that most members of a community favour abandonment. A successful shift requires that they manifest as a community – the will to abandon. This may take various forms, including a joint public declaration in a large public gathering or an authoritative written statement of the collective commitment to abandon. 5. A process of organized diffusion to ensure that the decision to abandon FGM/C spreads rapidly from one community to another and is sustained. Communities must engage neighbouring villages so that the decision to abandon FGM/C can be spread and sustained. It is particularly important to engage those communities that exercise a strong influence. When the decision to abandon becomes sufficiently diffused, the social dynamics that originally perpetuated the practice can serve to accelerate and sustain its abandonment. Where previously there was social pressure to perform FGM/C, there will be social pressure to abandon the practice. When the process of abandonment reaches this point, the social convention of not cutting becomes self-enforcing and abandonment continues swiftly and spontaneously. 6. An environment that enables and supports change. Success in promoting the abandonment of FGM/C also depends on the commitment of government, at all levels, to introduce appropriate social measures and legislation, complemented by effective advocacy and awareness efforts. Civil society forms an integral part of this enabling environment. In particular, the media have a key role in facilitating the diffusion process.
The trend towards medicalization and “symbolic” interventions. In some countries, FGM/C is performed in hospitals and health clinics by medical professionals who use surgical instruments, anaesthetics and antiseptics. Data from DHS demonstrate this trend towards “medicalization” in a number of countries, including Guinea and Mali in West Africa and Egypt in Northeast Africa, where most anti FGM/C efforts over the past 20 years have emphasised the procedures’ health risks. In the case of Guinea, for example, 21.8 per cent of girls and women aged 15 to 19 years were found to have undergone FGM/C at the hands of a medical professional, while this was estimated to be the case for less than 1 per cent of women between the ages of 45 and 49. The fact that certain medical professionals or health workers are known to be involved in the practice may contribute to a general misconception that FGM/C is somehow acceptable. In reality, the medical profession has widely condemned the medicalization of the practice. WHO has stated unequivocally that, “FGM of any form should not be practiced by health professionals in any setting - including hospitals or other health establishments,” and, as early as 1993, the World Medical Association explicitly condemned the practice of FGM/C as well as the participation of physicians in its execution. From a human rights perspective, medicalization does not in any way make the practice more acceptable. FGM/C remains a gender-based act of violence that compromises a girl’s or woman’s physical integrity. The same critique applies to symbolic forms of FGM/C, such as anaesthetized pricking of the clitoris, which have been proposed in recent years, within migrant communities in industrialized countries. Advocates of such “alternatives” argue that they reduce the harm to girls. In fact, a symbolic gesture is not guaranteed to satisfy the expectation that FGM/C involves the removal of flesh. This leaves girls vulnerable to “traditional” FGM/C at a later date, for example, in preparation for marriage. More fundamentally, “symbolic” interventions do not address the gender-based inequality that drives the demand for this service and may actually inhibit progress toward abandonment of the practice.