Female Genital Mutilation: Disabling Women and Disabling Society

Incontinence, infertility, infection, chronic pain. And there is more. Higher risk of HIV transmission, severe scarring, cysts, sexual dysfunction, difficulties with childbirth. And death. And that does not include resultant psychological or psycho-social illnesses and disability.

It is very difficult to imagine that if this list of complications were happening to men anywhere in the world - whatever resources were needed would not be used to search for and stop the cause of such harm. Yet, everyday in the world, today in 2004, there are approximately 6,000 girls and women mutilated or at risk of being mutilated. This amounts to some two million girls per year. The practice of Female Genital Mutilation (FGM) is deeply embedded in the attitudes, values and behaviors of society in numerous Africa, some Middle East countries, as well as in immigrant and some indigenous communities in parts of Asia and the Pacific, North and Latin America and Europe.

The definition of FGM, according to Amnesty International, is "the term used to refer to the removal of part, or all, of the female genitalia. There are several procedures that involve "partial or total removal of the external female genitalia or other injury to the female genital organs" (World Health Organization, 2002). WHO describes the various types as:

• Type I - excision of the prepuce, with or without excision of part of all of the clitoris;
• Type II - excision of the clitoris with partial or total excision of the labia minora;
• Type III - excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation);
• Type IV - pricking, piercing or incising of the clitoris and/or labia; stretching of the clitoris and/or labia; cauterization by burning of the clitoris and surrounding tissue;
• Scraping of tissue surrounding the vaginal orifice (angurya cuts) or cutting of the vagina (gishiri cuts);
• Introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of tightening or narrowing it; and any other procedure that falls under the definition given above.

Amnesty International has noted that there are traditions whereby a ceremony is held but no mutilation of the genitals occurs. This "symbolic" cutting might include "holding a knife next to the genitals, pricking the clitoris, cutting some pubic hair, or light scarification in the genital or upper thigh area".

In most cases, a small hole is left to allow the flow of urine and menstrual blood. In all but Type I FGM, it is often difficult to have sexual intercourse and it is almost always difficult if not impossible to have a safe vaginal delivery without extensive surgical cutting.

FGM is practiced on girls anywhere from infancy to adolescents, and infrequently on mature women. It is often performed by traditional practitioners in the girl's home or in a community with several girls around the same age. An older woman, a traditional healer, midwife, barber or qualified doctor are all used, depending on tradition, socio-economic status and access to services.

• Bleeding to death during and after the procedure (even in the case of physicians performing FGM)
• Severe shock and pain during circumcision
• Damage to the organs surrounding the clitoris and labia
• Acute and long-term urinary and reproductive disorders
• Clitoral inclusion cysts and keloids
• Vesicovaginal fistula - tissue between the vagina and bladder is badly injured and a hole develops causing debilitating incontinence
• A variety of pelvic infections
• Infertility and other complications caused by infections of the cervix, uterus and fallopian tubes
• Bladder over-distension leading to chronic urinary tract infection
• Kidney damage caused by inability or pain in urination
• Septicemia
• Tetanus - often caused by unhygienic utensils and conditions involved in the procedure
• Dysmenorrhea or at times, heavy menstrual bleeding
• Increased risk of hemorrhage during childbirth
• Pain during childbirth due to constriction of the vaginal outlet
• Chronic pelvic pain
• Pain - during and after intercourse
• Potential transmission of HIV - caused by the use of nonsterile and/or shared instruments during the procedure
• Increased susceptibility to hepatitis and other blood-borne diseases
• Personal accounts of anxiety, terror, humiliation and betrayal

If several of these conditions occur at the same time, or in concurrence, a cycle of lifetime illness and disability can also occur. Chronic pain is disabling. It can lead one to not want to or have the ability to eat - which can lead to malnutrition and other illnesses, etc. One infection can predispose a woman to often, more serious infections.

There is a reference to the health complications of FGM as the "three feminine sorrows". These include the sorrows on the day FGM takes place, the night of the wedding where often the woman has to be cut prior to intercourse and finally, when the woman gives birth and the vaginal opening is not large enough for a safe delivery (Fourcroy, J.L., "The three feminine sorrows", Hospital Practice. 1998; 33; 15-21). There are many examples where physicians perform extended episiotomies or cesarean sections to avoid further complications at delivery. Often, in both England and Denmark, the pregnant woman is deinfibulated in her second trimester. (Fourcroy, J.L., "Female Circumcision", American Family Physician. Vol. 60, Issue 2, August 1999).

• It can ensure virginity (maintain chastity before marriage)
• It can ensure fidelity during marriage
• It will increase male sexual pleasure
• It can secure or enhance fertility
• It can secure the economic and social (i.e. marital) future of daughters
• It will prevent the clitoris from growing long like a penis
• Through the reduction or elimination of the female genitalia, that this will attenuate the sexual desire in the female
• The female genitalia are considered both dirty and unsightly
• It will keep the female clean, and more hygienic
• It is an important ritual and part of the initiation of girls into womanhood
• It is "tradition" and part of one's cultural heritage
• That it is a religious mandate -- although the practice predates both Christianity and Islam

Although it is well-established that men hold most if not all of the power in communities that practice FGM, it is often women who state their support for the practice. Nearly all of the societies that practice FGM are those with strong patriarchal traditions. One immigrant living in Seattle, Washington, USA who asked to be circumcised replied to the doctor who tried to change her mind "Doctor, this is not my fight. We need your immunizations, food and education. We do not need your traditions... I would like your help to get a circumcision. It defines us as women of our tribe... Do not ask me to rebel against my people... " (Cichowski, S. "Beatrice's Choice", JAMA, Vol.288, No. 9, Sept, 2002).

There continues to be a discussion about the medicalization of FGM, both in western and African countries. They posit that if this is not done, women will often have FGM performed in non-sterile environments, increasing the long list of immediate and long-term complications. However, most advocates are opponents of this medicalization, stating that FGM is a human right issue equated with rape, domestic violence, pedophilia and female infanticide. These same arguments apply to those who advocate being "sensitive to the traditions of others" with regard to FGM and exploring safer alternatives for immigrant women. Again, the vast majority who oppose FGM call on precedents where international pressure and education influenced the reduction, cessation or eradication of procedures like the binding of feet in China, sex slavery, prenatal sex selection or female infanticide.

Many social communications and advocacy efforts regarding FGM and other issues relating to girls and women often have two major foci:

• Empowering girls and women in the community
• Education with regard to the health hazards of FGM (or any other issue regarding girls and women)

These are of course, critically important. However, when one reads about many local programs and communication strategies, there are lacunae that are obvious - and that are necessary if one is to remove the social legitimacy of FGM and make true and lasting changes. These are:

• Focusing on the attitudes and behavior of men in the community and household level
• Involving the community in the on-going process of developing social communications and behavior change communications - including and emphasizing men
• Identifying and rewarding positive deviance in the community - on the family, community and national level

UNICEF commissioned case studies from its Sudan and Kenya country offices in 2003 on the program and communication strategies regarding FGM. The consultant, Lopa Banerjee, rightly indicates that one of the most innovative approaches in Sudan, for example, has been to "challenge the practice of FGM in the public domain by Islamic clergy in an effort to de-link Islam from FGM and thus discourage its practice".

Ms. Banerjee notes that this is the case with most gender issues, "the practice of FGM is deeply embedded in social values and beliefs about women's identity, sexuality and power... the fundamental socio-cultural driver is the perceived need to control female sexuality". All of the reasons listed earlier in this article serve to legitimize the practice and its continuation. All of the reasons perpetuate the inferior status of girls and women and are "in direct violation of human rights within the Convention on the Rights of the Child (CRC) and the Convention on the Elimination of all forms of discrimination against women (CEDAW)".

A shift from health-based to rights-based messages is an approach that is supported by UNICEF and numerous international and national organizations. Participatory research has become critical - involving communities to become stakeholders in all aspects of development.

Another strategy employed by UNICEF and others in an attempt to have a greater impact on the attitudes and behavior of people on a given subject (e.g. early child development, HIV/AIDS, and here, FGM) is to strive towards integrated strategies, programs and communication. The hypothesis here is that one has a greater comparative advantage and better utilizes scarce resources when all Ministries are involved and coordinated. In the case of FGM, this means that the Ministries of Health, Education, Social Welfare, Religion - as well as NGOs, universities, media, UN agencies and other stakeholders develop and work toward an integrated, holistic and coordinated plan where each supplements and supports the work of others.

• Enacting legislation
• Institutionalizing community dialog
• Stronger engagement with key influence groups - religious leaders, community leaders and family leaders - in other words, men
• Intensive inter-sectoral programming
• Encouraging the dissemination of courageous decisions (otherwise known as 'positive deviance')
• Using modern as well as traditional forms of communication
• Encourage and support National Focal Points and coordination groups and centers
• Encourage civil society and government to create alternative skills for traditional circumcisers and empower them to advocate for the elimination of FGM

Gerry Mackie of St. John's College in Oxford, U.K., has written several articles on the parallels of ending FGM with footbinding in China. Today, in many communities, FGM is seen as part of family and social honor. He suggests that when "a critical mass of people in a... group pledge to refrain from FGM, then they knowledge that they are a critical mass... this makes it immediately in their interest to keep their pledges, and suddenly makes it in everyone else's interests to join them." If yesterday, one would not marry a woman who had not had FGM, today one would not marry a woman who did have FGM. This approach was used by anti-footbinding reformers around 1874 and by 1908 - much of the public had changed their view about the practice. (Mackie, G., 1998).

In the early 1950s, the UN Commission of the Status of Women and other UN bodies first began to focus on FGM (Carol Bellamy, UNICEF, 2003). Their goal was to "confront the problems of customs, ancient laws and rituals that harm women's health and well-being and trample on their rights".

African countries and their women and men are in the forefront of this activism. In 1997 a Symposium for Legislators was held in Addis Ababa, Ethiopia. The outcome was the "Addis Ababa Declaration" which "called on African countries to adopt clear policies and concrete measures aimed at eradicating or drastically reducing FGM by the year 2005.

In addition to national legislation, there is also the "Female Genital Mutilation and International Human Rights Standards (ACT 77/14/97). States are obligated to comply with these Standards.

Here is a partial list of examples of progress over the last two years:

• The outcome document of the UN General Special Session on Children, endorsed by 69 Heads of States and Government and 190 high-level national delegations including young people, set a goal to end FGM by the year 2010.
  
• Amnesty International issued a press release on February 6, 2004 calling for "International Zero Tolerance to FGM". This release was in anticipation of Zero Tolerance to Female Genital Mutilation Day on March 5, 2004. The release calls for a "Common Agenda to provide a common framework for all to intensify and coordinate activities at different levels while respecting their diversity". It states that thus far, only 14 African countries have adopted laws banning FGM. It encourages all African governments to ratify international instruments on human rights.
  
• On February 5, 2004, a congressional briefing was held on FGM in Washington, D.C. sponsored by the Population Reference Bureau and USAID. Both congressional staff and senior staff from various organizations working on FGM attended to discuss progress and review plans of action.
  
• There exists an informal Reference Group on Harmful Practices, alternately convened by members including UNICEF, WHO, UNFPA, UNIFEM and the Office of the High Commissioner on Human Rights.
  
• Amnesty International calls for a 10 point program of action for Governments to eradicate FGM. This includes:
  
  1. Affirm that FGM is an abuse of human rights, and recognize their obligation to end it. They should make a clear and unequivocal commitment to eradicate or drastically reduce the prevalence of the practice within a defined time frame.
     
  2. Set up mechanisms for consultation and collaboration with relevant non-governmental sectors (religious, health, women, human rights, development) as well as international organizations and UN agencies working on human rights, health and development.
     
  3. Undertake research into the practice of FGM in their countries. Information is particularly needed on its prevalence, physical and psychological effects, social attitudes and religions requirements. Research should also review the impact of efforts to date. In particular, work needs to be done to study the prevalence of FGM outside Africa, especially in the Middle East, Latin America and in many countries where it is practiced among immigrant communities.
     
  4. Review all relevant domestic legislation to see how effectively law and practice protect against FGM and comply with international standards, particularly CEDAW, the CRC and the Declaration on the Elimination of Violence against Women. Ensure that legislation complies with the recommendations of the UN Special Rapporteurs on violence against women and on traditional practices affecting the health of women and children.
     
  5. Ratify the International Covenant on Civil and Political Rights, International Covenant on Economic, Social and Cultural Rights, the Women's Convention, the CRC and all other relevant standards without limiting reservations or interpretive statements. Comply with their commitment to report to relevant treaty bodies, and to include specific mention of steps to prevent FGM in reports to all relevant treat bodies and human rights mechanisms.
     
  6. Ensure that FGM programs are integrated into all relevant areas of state policy. Departments of health should clearly prohibit medicalization of FGM, and move to incorporate this prohibition into professional codes of ethics for health workers. Departments of education, women's affairs, immigration and development should all include FGM programs, as well as addressing the underlying factors which give rise to FGM, such as access to education. Countries providing development assistance should identify ways of supporting FGM projects.
     
  7. Recognize FGM as a form of gender-based persecution falling within the scope of the UN Convention relating to the Status of refugees. States should adopt and implement the recommendations set out in the Guidelines on the Protection of Refugee Women of the UN High Commission for Refugees.
     
  8. Carry out widespread public information programs using relevant media. These should be tailored to specific groups, such as men, women, young people, children, the elderly, influential community figures, religious scholars, and those who carry out FGM.
     
  9. Support the work of NGOs and individuals working against FGM. Provide them with protection against threats and other attempts to undermine their work.
     
  10. Take an active role in supporting regional and international initiatives to combat FGM, such as the WHO, UNICEF, UN Population Fund (UNFPA). Encourage adoption by the OAU of the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children (IAC) Addis Ababa Declaration. Endorse and support the work of the UN Special Rapporteurs on violence against women and on traditional practices affecting the health of women and children.
      
• Amnesty International (AI) supports a "Special Project on Female Genital Mutilation and Human Right". The aim is to conduct research on FGM in order to support advocacy and education campaigns. The project currently focuses on Sudan, Kenya and Senegal but also works within the broader movement in Africa and the world. AI supports a FGM Project Officer based in Kampala, Uganda as well as a Project Manager based in London.
  
• UNICEF supports numerous FGM initiatives including:
  
  • In Djibouti, there are social mobilization efforts based on the training of religious and community leaders as well as advertisements against FGM on television and radio
    
  • In Senegal, support was given to NGOs to help create a movement against FGM. UNICEF has supported this NGO, TOSTAN, since its inception 16 years ago. They have primarily worked on human rights with communities at the grass roots level. This work has helped lead toward the Parliament of Senegal approving legislation to ban FGM. The model is being used to shape a global strategy.
    
  • In Egypt, UNICEF worked with the Ministry of Insurance and Social Affairs to conduct a baseline survey in 26 villages to assess the knowledge, attitudes and practices of families with regards to FGM. They then supported the Ministry in creating a group of advocates against FGM including social workers, and members of the Government. Training took place with physicians, nurses and traditional midwives to help enable them to warn families of the dangers of FGM.
    
  • In Somalia, workshops have been held with UN agencies and NGOs to discuss the Koranic interpretation of FGM together with medical complications. Workshops resolutions were passed.
    
  • Internally, the Child Protection Sections work closely with the strategic information unit of UNICEF on database and indicators for FGM. An inter-sectoral, inter-divisional task force meets to discuss issues of child violations associated with traditional practices and culture around FGM and other specific themes
    
• UNICEF's Executive Director, Carol Bellamy, recently outlined what would constitute a "protective environment" with regard to FGM and Female Genital Cutting (FGC). It includes:
  
  1. Working with families and communities in order to change attitudes, traditions, customs and practices that promote gender inequality and discrimination and lead to FGM/C. NGOs should continue to play a strong role in this effort.
     
  2. Building capacity of all development workers including health and social workers, school teachers, police officers, in order to identify and respond to child protection problems such as FGM/C.
     
  3. Engaging civil society, media, parliamentarians, religious and opinion leaders in open discussions and debates on ending FGM/C.
     
  4. Involving children, adolescents and young people in open debate about ending FGM and listening to their voices. Adolescents, especially girls, should be empowered with information, knowledge and life skills to protect themselves and their younger sisters from FGM/C.
     
  5. Getting full Governments' commitment to ending FGM/C: Government's interest in, recognition of, commitment to and capacity for leading actions are essential elements for ending FGM/C. Governments are also accountable for implementing the concluding observations and recommendations made the UN Committee on the Rights of the Child (CRC) and the Committee on the Elimination of Discrimination against women (CEDAW).
     
  6. Promoting an adequate national legislative framework and its consistent implementation.
     
  7. Improving services for recovery, rehabilitation and reintegration of girls and women who suffer from FGM/C and its lifelong consequences.
     
  8. Monitoring and reporting on FGM/C requires an effective monitoring system as part of the national social statistics mechanism that records the prevalence, incidence and strategic responses.
     
• In Kenya, a group of young women from various homes defied their families' wishes and went to see a lawyer trying to prevent them from having to submit to FGM. The lawyer brought the case to trial and was able to get an injunction stating that the parents could not make them submit to FGM without their consent.
  
• In February 2003, the first ladies of Burkina Faso, Nigeria, Mali and Guinea jointly condemned FGM at a meeting in Ethiopia. They called it "the most widespread and deadly of all violence victimizing women and girls in Africa". Activists from these and other African nations urged leaders to places (and enforce) bans on FGM. Some of the participants included men who wore signs saying "I am very happy to be marrying an uncircumcised woman".
  
• A joint WHO/UNICEF/UNFPA policy statement on FGM and plan to accelerate the elimination of FGM has been published. Several countries where FGM is a traditional practice have or are developing national plans of action to prevent FGM.
  
• WHO has developed training materials for integrating the prevention of FGM into nursing, midwifery and medical curricula as well as for in-service training of health workers.
  
• In Canada, FGM is considered an assault and prohibited under law. In addition, the National Organization of Immigrant and Visible Minority Women of Canada distribute a manual for health care workers to "educate participants about the health and legal consequences of FGM, to correct misperceptions and fallacies about the tradition and to support efforts to eradicate the practice". There is a federal Interdepartmental Working Group on FGM whose mandate is "to identify and promote methods to prevent the continuation of FGM by families now living in Canada". (www.cirp.org)
  
• Laws explicitly prohibiting FGM exist in several countries outside Africa, including Sweden, Switzerland, the UK and USA. Other Western countries have child protection laws which can be applied to protect girls from being genitally mutilated (UK and Australia). And numerous people have been convicted in France under its' assault laws for performing FGM or causing FGM to be carried out.
  
• On March 3, 2004, The United Kingdom further restricted the illegal practice of FGM in new laws prohibiting families from sending their daughters abroad for the procedure. FGM was outlawed in 1985, but many immigrant families intent on having the procedure send their daughters overseas for FGM. The law is applicable, regardless of whether the practice is legal in the country the family visits. Thos found guilty can receive a sentence of 5 -14 years in prison. (U.N. Wire, March 4, 2004)

I recently reviewed a film on FGM entitled "The Day I Will Never Forget" by filmmaker Kim Longinotto. Viewing the film, and writing this article, is an experience I will never forget. In the film, a girl of 8 or 9 years, Fouzia, writes a poem about the day she was circumcised. This day continues to live on in her psyche, her body, her soul. The horror just doesn't happen for one day. It's real, and symbolic effects can last a lifetime. Reading and seeing accounts of female genital circumcision together with statements made by both men and women supporting the practice demonstrate how very deep this tradition lies within many individuals and groups. It is obvious that the road ahead will be long and difficult. It will take millions of Fouzias, and millions of us, to put a stop to FGM. We must.

Resources and references
www.ovid.com 
www.jama.com 
www.amnesty.org 
www.who.org 
www.fgmnetwork.org 
www.unicef.org 

Banerjee, L. "A journey together... Programme and Communication Strategies for Child Protection", UNICEF Headquarters joint initiative of the Programme Communication and Social Mobilisation Unit and the Child Protection Section, New York, 2003 March

Eke N, Nkanginieme K.E. "Female Genital Mutilation: A Global bug that should not cross the millennium bridge", World Journal of Surgery. 23(10):1082-6: discussion 1087, 1999 Oct.

Epstein, D, Graham, P, Rimsza, M. "Medical Complications of Female Genital Mutilation" Journal of American College Health. Vol. 49, Issue 6, 2001 May

Mackie, Gerry. "A Way to End Female Genital Cutting" www.fgmnetwork.org, 1998

Rouzi, A.A., Sindi, O., Radhan B., Ba'aqeel H. "Epidermal clitoral inclusion cysts after type I female genital mutilation", American Journal of Obstetrics & Gynecology. 185(3): 560-71, 2001 Sept.

Strikland, J.L., "Female circumcision/female mutilation", Journal of Pediatric and Adolescent Gynecology. 14(3): 109-12, 2001 Aug.

Other organizations concerned with FGM
Inter-African Committee on Traditional Practices Affecting the Health of Women and Children (IAC)
Forward International
Minority Rights Group
Commission pour l'Abolition des Mutilations Sexuelles (CAMS)
Research Action Information Network for Bodily Integrity of Women (RAINBO)
Equality Now

Author's postscript:

I struggled with this article and the associated film review because I have worked in many Muslim countries, including Bangladesh, Pakistan, the Maldives and Indonesia, and with very religious communities of all faiths on many continents, where the vast majority do not practice FGM. It does seem to be the case that where it is practiced, religious beliefs are often cited as one of several reasons for its continuance. However, I have also met, worked with and lived in close quarters with many people, representing all the major religions, who do not support or tolerate the practice.

In these articles I have tried to include statements and information from a wide range of sources and to focus on the cultural, medical and human rights aspects of FGM. Finally, I hope these articles reflect what I have learned about how important it is not to generalize or assume that all members of any group think alike, regardless if we are considering gender, ethnicity, religion, national origin or disability.

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