Female Genital Cutting: A Persisting Practice
Abstract
More than 130 million women worldwide have undergone female genital cutting (FGC). FGC occurs in parts of Africa and Asia, in societies with various cultures and religions. Reasons for the continuing practice of FGC include rite of passage, preserving chastity, ensuring marriageability, religion, hygiene, improving fertility, and enhancing sexual pleasure for men. The World Health Organization has classified FGC into 4 types depending on the extent of tissue removed. Immediate complications include hemorrhage, infection, sepsis, and death. Long-term complications include pain, scarring, urinary issues, and poor obstetric and neonatal outcomes. Efforts are being made nationally and internationally to eradicate this practice.
Female genital cutting (FGC), also known as female circumcision or female genital mutilation, is an ancient practice that predates the Abrahamic religions. Fraught with medical, legal, and bioethical debates, FGC is practiced in 28 African countries and some countries in Asia. In 1997, the World Health Organization (WHO), United Nations Children’s Fund, and United Nations Population Fund issued a joint statement that defined FGC as “all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or other non-therapeutic reasons.”1
Approximately 3 million girls every year are at risk of undergoing FGC.2 The health, psychological, and sexual complications of FGC depend on the type of procedure that is performed, sterility during the procedure, the experience of the operator, and the social atmosphere at the time the cutting is performed.
Classification of FGC
WHO and other United Nations organizations have recently issued a new joint statement and have broadened the FGC classification (Figure 1).3 Type I, also known as clitoridectomy or sunna, involves removing part or all of the clitoris and/or the prepuce. Type II, also known as excision, involves removing part or all of the clitoris and labia minora, with or without excision of the labia majora. Type III, the most severe form, is also called infibulation or pharaonic. It entails removing part or all of the external genitalia and narrowing the vaginal orifice by reapproximating the labia minora and/or labia majora. This infibulated scar covers the urethra and most of the introitus, leaving a small hole for urination and menses. Type IV is the mildest form and includes any form of other harm done to the genitalia by pricking, piercing, cutting, scraping, or burning.
The prevalence of FGC varies from nation to nation, and even within a nation some areas may have never heard of FGC, whereas in other areas FGC is performed on 90% of girls (Figure 2). Type I is practiced mostly in Ethiopia, Eritrea, and Kenya. Type II is performed in parts of West Africa, such as Benin, Sierra Leone, Gambia, and Guinea. Somali, Northern Sudanese, and Djibouti women undergo type III FGC.4 The Northern Nigerians perform type IV by introducing corrosive material in the vagina (known as gishiri) or scraping the vaginal orifice (known as angurya).5
History
The origins of FGC are a mystery. It is thought to have existed in ancient Egypt, Ethiopia, and Greece.6 The practice transcends religion, geography, and socioeconomic status. Although FGC predates Islam, a small number of Muslims have adopted the practice as a religious requirement. As late as the 1960s, American obstetricians performed clitoridectomies to treat erotomania, lesbianism, hysteria, and clitoral enlargement.7
Girls typically undergo FGC between the ages of 6 and 12 years. It is performed on newborns, at menarche, and prior to marriage. Usually girls are aware that they will be cut some day, and some eagerly anticipate it. Villagers gather girls and celebrate the rite of passage with food, song, and gifts.6
Generally, midwives or trained circumcisers go from village to village and perform the cutting with no anesthesia, antibiotics, or sterile technique. Their instruments are knives, razors, scissors, or hot objects that are reused. After the tissue has been excised, sutures, thread, and local concoctions such as oil, honey, dough, or tree sap are used to ease bleeding. Postoperatively, wound care depends on the extent of damage. Girls who have undergone type I usually heal within a few days, whereas girls who have undergone type III require bed rest for approximately 1 week. Their thighs and legs are bound together to ensure proper healing of the infibulated scar.
Some girls are unaware they will be cut. FGC is performed on these girls suddenly, without mental preparation, celebration, or fanfare. In this situation, girls can be emotionally traumatized. In other cases, nurses and physicians perform FGC in their offices under anesthesia in order “to protect” girls from complications. The international medical community strongly opposes medicalizing FGC on ethical grounds. Medical involvement is also seen as justifying and perpetuating a practice that should instead be eradicated.8
A Persisting Practice
Parents who continue this practice are compassionate and loving. They believe that they are protecting their daughters from harm. Reasons that parents and practitioners give for the procedure include rite of passage, preserving chastity, ensuring marriageability, improving fertility, religious requirement, hygiene, and enhancing sexual pleasure for men. Parents who insist that their daughters undergo FGC are driven by a fear that their daughters may never marry. An unmarried daughter is ostracized and shunned in these societies, and may be seen as unclean, unhygienic, and perhaps even labeled as a prostitute. Some societies believe that the clitoris is toxic, and if during child birth the clitoris touches the baby’s head, the baby will die. Some societies believe that if unchecked, the clitoris will grow until it touches the ground. Thus, removing the clitoris improves survival, ensures beauty, and preserves their daughter’s reputation.
Complications and Treatment
Women with types I and II FGC who survive the procedure rarely have long-term complications given that they do not have an infibulated scar covering their external genitalia. Women who undergo type III FGC are at the highest risk for immediate and long-term complications. The most common immediate complications are uncontrolled bleeding, fever, wound infection, sepsis, and death.4 The most common long-term complications are dysmenorrhea, dyspareunia, recurrent vaginal and urinary tract infections, infertility, cysts, abscesses, keloid formation, difficult labor and delivery, and sexual dysfunction.4,9–13
Infertility is a devastating psychosocial complication to the infibulated woman. Her infertility rate can be as high as 30%.12,13 This infertility rate is secondary to both anatomic and psychologic barriers. The infibulated scar that supposedly protects girls from pregnancy out of wedlock becomes the obstacle that prevents them from getting pregnant within marriage. With multiple coital attempts over several months and using ample lubricants, the scar can stretch, but coitus is still very painful. This creates an unhealthy and distressing sexual relationship between husband and wife. Women fear that they may never become mothers, and husbands question their masculinity.14 Although some studies have demonstrated that men prefer to marry uncircumcised women,15 other studies have found the opposite to be true.16
Once pregnant, infibulated women face another daunting challenge: labor and delivery. In a large study, women with FGC were found to be at an increased risk of having adverse obstetric outcomes, including postpartum hemorrhage, episiotomies, cesarean deliveries, extended maternal hospital stay, infant resuscitation, stillbirth, or neonatal death. These risks increased with the severity of FGC.17
Given the degree of damage and the multiple complications from the infibulation scar, women with type III FGC can be offered a defibulation procedure to treat long-term complications. Defibulation, a surgical procedure performed under regional or general anesthesia, opens the infibulated scar and exposes the urethra and introitus. In parts of Somalia and Djibouti, defibulations are performed by midwives, traditional birth attendants, or the circumcisers themselves. Opening the scar enables women to become fertile, eases dyspareunia, and improves labor and delivery experiences. One study found that defibulation not only resolved long-term complications, but that almost 50% of the women who were defibulated had an intact clitoris (Figure 3).18
How Can FGC Be Stopped?
Over the past 30 years, grassroots, national, and international organizations have actively worked on eradicating this practice. FGC has been outlawed in most countries, but because governments rarely enforce these laws they are essentially ineffective. FGC is recognized as a violation of human and child rights. But when eradication efforts are made from Western nations, the issue becomes emotionally charged. Grassroots programs organized by local and national groups that focus on increasing human rights awareness and knowledge have had great success in reducing the incidence of FGC. Communities are voicing their desire to abandon the practice, religious institutions are indicating that FGC is not a requirement, and governments are approving programs that educate the nation about the harms of FGC.2 Along with prevention, focus must be made on assisting those who have already undergone FGC and are living with long-term complications. Medical institutions must participate in promoting defibulation procedures and helping women live pain-free lives.
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