Female genital mutilation
Female genital mutilation is the cutting, or partial or total removal, of theexternal female genitalia for cultural, religious, or other non-medical reasons. It is usually performed on girls between the ages of 4 and 10. It is also called female circumcision, a term which the American College of Obstetricians and Gynecologists encourages all health professionals to use.
Female genital mutilation (FGM) cuts or removes the tissues around the vaginathat give women pleasurable sexual feelings. This procedure, which is thought to have begun about 6,000 years ago, is used for social and cultural control of women's sexuality. In its most extreme form, infibulation, where the girl's vagina is sewn shut, the procedure ensures virginity. In some cultures, this procedure is considered a rite of passage for young girls. Families fearif their daughters are left uncircumcised, they may not be marriageable, or the girl might bring shame to the family by being sexually active and becomingpregnant before marriage. Circumcision is also seen as a cleansing ritual, as a boost to fertility or to male sexual pleasure, and as a cure for "sexualdeviance." In some African countries, infibulation is tied to gender identityas well as to the girl's identity as a virgin. Girls who are not circumcisedare ostracized and do not marry. Circumcision is seen as a guarantee that ayoung woman is a virgin with no chance of bearing a child of another lineage.In the Arab world, the concentration on patrilineal purity is of primary importance. Ironically, there are reports of some young women who are have already been sexually active before FGM is performed.
Female genital mutilation is often seen as a self-enforcing convention because it is carried out before puberty and since it is widely practiced, most circumcised women have no basis for comparison. Parents who insist on FGM for their daughters are seen as loving and caring. In another irony, many girls whoundergo FGM describe the feeling of betrayal by their mothers as being worsethan the physical pain of the procedure.
It is illegal to perform female genital mutilation in many countries, including the United States, Canada, France, Great Britain, Sweden, Switzerland andsome African countries. This procedure is usually done in the home or somewhere other than a medical setting. Often, it is performed by a family member orby a local "circumciser," using knives, razor blades, or other tools that may not be sterilized before use.
Female circumcision includes a wide range of procedures. The simplest form involves a small cut to the clitoris or labial tissue. A Sunna circumcision removes the prepuce (a fold of skin that covers the clitoris) and/or the tip ofthe clitoris. A clitoridectomy removes the entire clitoris and some or all ofthe surrounding tissue. The most extreme form of genital mutilation is excision and infibulation, in which the clitoris and all of the surrounding tissueare cut away and the remaining skin is sewn together. Only a small opening is left for the passage of urine and menstrual blood. The World Health Organization (WHO) estimates that over 120 million girls and women have undergone some form of genital mutilation. It is a very deeply rooted cultural and religious tradition still practiced in over 26 African, Middle Eastern, and Asian countries, with up to 2 million girls at risk each year.
As more people move to Western countries from countries where female circumcision is performed, the practice has come to the attention of health practitioners in the United States, Canada, Europe, and Australia. In an effort to integrate old customs with modern medical care, some immigrant families have requested that physicians perform the procedure. While trying to be sensitive tocultural traditions, health care providers are sometimes put in the difficult position of choosing to perform this procedure in a medical facility undersanitary conditions, or refusing the request, knowing that it may be done anyway with no medical supervision. Some families take their daughters back to the country they immigrated from in order to have the girls circumcised. Manynational and international medical organizations including the American Medical Association, Canadian medical organizations, and the World Health Organization oppose the practice of female genital mutilation. The United Nations considers female genital mutilation a violation of human rights.
A girl or young woman who has recently had the procedure performed may require supportive care to control bleeding and antibiotics to prevent infection. Women who were circumcised as children may require medical care to treat complications. Circumcised females may need to have the labial tissue cut open inorder to have intercourse and to allow childbirth. Aftercare should be provided with a supportive and nonjudgmental approach toward the girls and women who have undergone this procedure. Western physicians taking care of pregnant women who have been circumcised need to be aware of the potential for added medical complications. In some countries such as England and Denmark, obstetricians will routinely anesthetize pregnant circumcised patients during the second trimester and surgically separate the tissue that has been sewn shut, in aprocedure known as deinfibulation. Deinfibulation reduces some of the riskscircumcised women face during childbirth. When circumcised women give birth in Western countries, the patients sometimes ask to be reinfibulated-that is,to have the labia sewn shut again-so they can continue to conform with the cultural expectations of their country of birth. However, FGM is now prohibitedin many countries. Some physicians are thought to avoid the medical and ethical difficulties of childbirth of circumcised women by delivering such babiesby cesarean section, or by performing an extended episiotomy, both of whichare common in Western medicine. In delivery by cesarean section, the baby isremoved through a surgical opening and it does not travel through the birth canal. An episiotomy is an incision of the vulva made to avoid tearing the tissue during vaginal delivery.
The immediate risks after FGM are hemorrhage (excessive bleeding), severe pain, and infection (including abscesses, tetanus, and gangrene). The most severe consequence is death due to excessive blood loss. Circumcised women are also at risk for pelvic infection of the uterus and fallopian tubes. Women beingforcefully held down for FGM risk fracture or dislocation of hip and leg bones. Long-term complications include scarring, interference with the drainageof urine and menstrual blood, chronic urinary tract infections, pelvic and back pain, and infertility. A chronic urinary tract infection can travel to thebladder and kidneys, causing renal failure, septicemia (blood poisoning) ordeath. Since there is no assurance of sterile cutting instruments, the womanis also at risk for HIV and AIDS. Sexual intercourse can be painful. Complications of childbirth are also a risk. Deinfibulation, which may be required toprevent further physical trauma, can lead to hemorrhage or fistulas (abnormal openings) of the genital area.
In Africa, where FGM is most common, there is disagreement about the best approach to curtail the practice. Some countries have attempted community-basededucation as the best long-term strategy. In Senegal, where Parliament bannedFGM in January 1999, there are mixed feelings. Some communities were beginning to make inroads with a health education campaign, then the national law criminalized up to 2 million citizens and sowed distrust among friends, relatives and neighbors who had been working together. Critics charge that Senegal passed the law only to appease Western sensibilities. In defiance, one southern village conducted a mass circumcision of 120 girls just before the law wentinto effect. Female genital mutilation is also banned in Burkina Faso, the Central African Republic, Djibouti, Ghana, Guinea and Togo. Uganda discouragesFGM and Egypt banned the practice in 1998 with a statement that it had no place in Islam.
Kenya recognized the ritual aspect of FGM and developed an alternative rite of passage for girls of circumcision age. In the Tharaka Nithi district of Kenya, new festivals have been organized for the months of August through December, when circumcision would usually be performed. During a week of seclusion,girls in the alternative program are educated on a wide range of subjects, including personal hygiene, relationships, dating and courtship, and marriage.The program also covers topics such as peer pressure, male and female reproductive anatomy, menstruation, conception and prevention of pregnancy, the consequences of teen pregnancy, sexually transmitted diseases, HIV and AIDS, andways to prevent exposure. Positive aspects of tribal culture are taught, such as self esteem, decision making, and respect for elders.
Tanzania adopted a program for initiation without mutilation in 1998. Girls age 10 to 13 receive instruction in domestic chores, midwifery, hygiene, sex and pregnancy over a two-week period. For the initiation ritual, the girls arebeautifully dressed and participate in a ceremony where they demonstrate their readiness to receive instructions in womanhood. The whole village joins indrumming, singing, dancing and feasting to celebrate the new phase of the girls' development. The Inter-African Committee has urged all African countriesto develop initiation without mutilation.
A few physicians and circumsisers have been indicted for performing FGM in Ghana and Egypt, usually in cases where the young woman has bled to death, butprosecutions are very rare. Western observers speculate that few African countries dare to enforce the law. In Guinea, the penalty for FGM is death, but the sentence has never been applied. Typically, African aid workers oppose criminalization of FGM. Their cohorts in Western capitals, where policy is made,are more likely to favor stiff penalities. Many Africans are unaware of thehealth risks and aid workers see a focus on health education as the best avenue for change. One example of an ongoing program is the Childbirth Picture Book campaign launched by the Women's International Network in 1982. This educational program uses photographs and text in many languages in a special effort to show birth attendants, midwives, healers and other practitioners of traditional medicine the dangers of FGM.
Many cultures that accept FGM are Islamic, and Islam has been seen as being tied to FGM because of its insistence on virginity before marriage, a practicewhich circumcision is supposed to insure. However, this common belief has been challenged by Islamic scholars. Other faiths that have supported FGM include Coptic Christianity as practiced in Egypt; Orthodox and Ethiopian Jews; and the Falashas, a group of Ethiopians Jews who live in Israel. The literatureon FGM includes accounts of circumcision as a rite of passage for all Arab females.
An estimated 137 million women in at least 28 African countries have undergone circumcision. Africans point out that most circumcisers are women. The Centers for Disease Control estimates that 168,000 females in the United States are at risk for having FGM performed. The CDC places the highest risk on African immigrant women living in large metropolitan areas.
Female genital mutilation is laden with many intercultural taboos. When African leaders were fighting against British colonialism during the 1980s, the male leaders defended FGM as a private matter and accused feminists who opposedFGM of "cultural imperialism." However, some African women who desire changecounter that "culture is not torture." Africans point to Western practices such as bulimia, anorexia, liposuction, silicone breast implants, repeated facelifts-all in pursuit of idealized feminine beauty-and ask how Westerners cansit in judgment of Africans. Another collision of cultures occurs when Africans come to the United States and are shocked at the sexual activity of American teenagers. Some Africans react with renewed insistence on FGM as a way ofmaintaining their family honor.