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Genital Mutilation of Girls and Women

Ritual injury of female genitals usually goes way beyond male circumcision

Original cartoon by Alex Martin
Source: Original cartoon by Alex Martin

Male circumcision, the focus of my previous blog piece ( Rites of Circumcision , posted October 10, 2018), although not universal, occurs widely. Female genital mutilation (FGM) — also called genital cutting or female circumcision — is geographically far more localized. The World Health Organization (WHO) defines FGM 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". Estimates of 200 million victims of FGM alive today, with 3 million new cases added annually, are given in a 2016 pamphlet from the United Nations Children's Fund (UNICEF).

Geographical distribution

M. Tracy Hunter, using data from United Nations Children’s Fund (UNICEF), 2013. File licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license.
World map showing % of girls/women aged 15-49 years who have undergone Female Genital Mutilation (FGM). Grey areas indicate minimal levels of FGM, although it is practiced in parts of the Middle East and in areas of Asia, Australia, Europe, and North America by immigrants from countries where FGM is prevalent.
Source: Wikimedia Commons. Author: M. Tracy Hunter, using data from United Nations Children’s Fund (UNICEF), 2013. File licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license.

UNICEF indicates that FGM occurs predominantly in Africa, but also exists in the Middle East (Iraqi Kurdistan, Yemen) and in South-East Asia (Indonesia). FGM is currently known to be present in 27 African countries, extending west-to-east from Senegal to Somalia and south-to-north between Tanzania and Egypt. Reported incidences range from 2% for Niger up to 98% for Somalia. High frequencies are also documented for Guinea (96%), Egypt (91%), Mali (89%), Sudan (88%) and Sierra Leone (88%).

But little information is available for countries outside Africa. In a 2016 Reuters report, Emma Batha noted that FGM is practiced in at least 15 countries not shown on the UNICEF map. Her survey of Asia indicates high levels in India, Pakistan, Maldives, Thailand, Malaysia, Singapore, Brunei and Indonesia. The 2016 UNICEF pamphlet does briefly mention that FGM occurs in India, Malaysia, Oman, Saudi Arabia and the United Arab Emirates and even suggests possible occurrence in South America (Colombia). Yet available evidence for those regions is limited to anecdotes or small-scale studies and proper data are lacking. Activism still focuses mainly on Africa, underplaying the problem in Asia.

Image created by Kaylim at English Wikipedia, 2007. Transferred from en.wikipedia to Wikipedia Commons. Released into the public domain by Kaylima at the Wikipedia project.
Diagrammatic representation of normal appearance of vulva and three main types of female genital mutilation recognized by WHO.
Source: Image created by Kaylim at English Wikipedia, 2007. Transferred from en.wikipedia to Wikipedia Commons. Released into the public domain by Kaylima at the Wikipedia project.

Types of FGM

A widely used WHO classification recognizes three main categories of FGM with increasing severity: Type I — Removal of the clitoral hood ( prepuce ), part or all of the clitoris, or both. Type II — Partial or complete removal of the clitoris ( clitoridectomy ) along with the inner lips ( labia minora ), and sometimes the outer lips ( labia majora ) as well. Type III — Removal of most or all of the external genital structures, with or without the clitoris, along with cutting the inner and/or outer lips and stitching in the midline to narrow the vaginal opening ( infibulation ). A fourth category, Type IV, includes various other mutilations of female genitals for non-medical purposes: pricking, piercing, incising, scraping, cauterization.

This classification underlines wide variation in severity of FGM, extending from removing the clitoral hood to obliterating almost all externally visible genital structures. In the extreme Type III, the stitched outer lips leave just a small hole for urine and menstrual fluid to pass. That hole is subsequently enlarged ( deinfibulation ) to open up the vagina for regular coitus, and further widening is performed before childbirth. A woman can hence undergo several opening and closing interventions.

From UNICEF 2013, via Wikimedia Commons. File in the public domain because the facts are not copyrightable, and the presentation does not meet the threshold of originality.
Age ranges (percentage distributions) at which FGM cutting occurred, as reported for mothers, for 22 countries on the African continent.
Source: From UNICEF 2013, via Wikimedia Commons. File in the public domain because the facts are not copyrightable, and the presentation does not meet the threshold of originality.

Timing of FGM shows comparably extensive variation. It may be performed at any point between a few days after birth and puberty, and (rarely) even in adults. Nevertheless, a 2013 UNICEF pamphlet revealed that most girls undergo FGM before five years of age in roughly half of countries with available data.

Buster Baxter (2010). File licensed under Creative Commons Attribution-Share Alike 3.0 Unported, 2.5 Generic, 2.0 Generic and 1.0 Generic licenses.
Different patterns of FGM Types in 6 African Countries. Figure based on data from WHO (2006).
Source: Wikimedia Commons; author: Buster Baxter (2010). File licensed under Creative Commons Attribution-Share Alike 3.0 Unported, 2.5 Generic, 2.0 Generic and 1.0 Generic licenses.

Female genital mutilation and male circumcision

FGM is sometimes called female circumcision , but this evokes considerable opposition. In her 1999 book Sex and Social Justice , Martha Nussbaum neatly states one major reason: “The term 'female circumcision' has been rejected by international medical practitioners because it suggests the fallacious analogy to male circumcision ……… " Yet Brian Earp has cogently argued that crucial ethical considerations apply to both male circumcision and FGM, such that consideration of both together is warranted. Which viewpoint is most convincing? To tackle that question, we must consider the basic biology of male and female genitals.

Wikimedia Commons. Work is in the public domain in its country of origin and other countries and areas where the copyright term is the author's life plus 100 years or less.
Stages in the development of human male and female external genitals. Illustrator: Henry Vandyke Carter. Source: Henry Gray Anatomy of the Human Body (1918).
Source: Wikimedia Commons. Work is in the public domain in its country of origin and other countries and areas where the copyright term is the author's life plus 100 years or less.

Despite major differences between external genitals in adult men and women, their early development shows a striking common origin. The penis and the clitoris both originate from a small genital tubercle . The male foreskin and the clitoral hood — both anatomically called a prepuce — have a similar shared origin. Moreover, a small cleft lies beneath the genital tubercle in both sexes. In females, this is subsequently enlarged to form the vagina, but it closes in males, leaving a seam ( median raphe ) beneath the penis.

Most cases of FMG clearly go far beyond male circumcision. Removing the foreskin is anatomically equivalent to removing the clitoral hood. The human clitoris is actually an extensive structure (see my blog pieces Does Size Matter for Women? , posted April 20, 2015 and Intimately Connected , posted September 13, 2016). But most components corresponding to individual parts of the penis, notably erectile tissues, lie within a woman’s body. Partial or complete removal of the external bulb of the clitoris is actually equivalent to cropping the head of the penis (both being the glans ). This alone indicates that removing the externally visible clitoris, found with all three main types of FGM, is more drastic than merely removing the male foreskin. Additional mutilations with Types II and III obviously involve even greater injury.

Health implications

FGM can be confidently expected to have major implications for women’s health, especially if performed under unsanitary conditions. Some have claimed that it actually has health benefits, but convincing evidence is lacking. A 2018 WHO pamphlet states unequivocally: “FGM has no health benefits, and it harms girls and women in many ways. It involves removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls' and women's bodies.”

Immediate, sometimes fatal, complications of FGM can include severe pain and shock, hemorrhage, genital tissue swelling, injury to surrounding tissues, wound healing problems, fever, infections, and urinary problems. Over the longer term, women who survive FGM suffer multiple consequences. These may include painful urination, urinary tract infections, vaginal problems, menstrual problems, scar tissue formation, sexual problems, psychological problems, increased risk of complications during childbirth, and an increased likelihood of perinatal death.

Studies of adverse outcomes of FGM

Because of reliable evidence regarding the effects of FGM on women’s reproductive health is scarce, WHO established a Study Group on Female Genital Mutilation and Obstetric Outcome. This led to a collaborative prospective study in six African countries — Burkina Faso, Ghana, Kenya, Nigeria, Senegal, Sudan — with results published in 2006. Almost 30,000 women attending medical facilities for singleton births in 2001-2003 were examined before delivery to determine whether or not FGM had been performed. In comparison to women without FGM, significant increases in adjusted relative risks of certain obstetric complications were found with FGM, with risks generally increased according to the severity of cutting. For instance, the risk of Caesarean section was 3% greater with Type I, 29% greater with Type II and 31% greater with Type III. With other conditions, risk increased even more steeply. For postpartum hemorrhage, the increase was 3% with Type I, 21% with Type II and 69% with Type III. Risks for infant resuscitation and stillbirth or early neonatal death showed a similar pattern. The researchers estimated that FGM leads to an extra one to two perinatal deaths per 100 births.

Since 2006, increasing awareness of FGM-related health problems has triggered much new research. No effective overview is yet available, but recent reports from individual regions with high FGM prevalence offer instructive pointers. In one example, a prospective case-control study by Sharifa Alsibiani and Abdulrahim Rouzi examined impacts of FGM on sexual function in women in Saudi Arabia. They compared 130 women with FGM with an equal number of mutilation-free women. For desire or pain, no significant differences were found. By contrast, significant differences were found for arousal, lubrication, orgasm, satisfaction and an overall score for sexual function.

A 2013 report by Abdel Raof Sharfi and colleagues reviewed immediate and longer-term complications of FGM among Sudanese women. Data were obtained retrospectively from two groups, the first containing 1200 university students representing a broad spectrum of ethnic and cultural groups and the second comprising 800 outpatients attending a university urology clinic in Khartoum. Of all women, 1468 (73%) were identified as victims of FGM, which was generally carried out before age six (96.9% of cases), predominantly by midwives in home settings. 267 immediate and 618 longer-term complications were identified, the most serious being hemorrhage, blood-poisoning and opening of a fistula connecting the bladder to the vagina.

In a third regional report published in 2018, Kiros Gebremicheal and colleagues examined birth complications of FGM in the Somali region of Ethiopia, where the prevalence is highest. They compared childbirth in 142 women with FGM and 139 without. Overall, the presence of FGM was significantly associated with a tripled risk of blood loss after birth, as well as increases of 150% in frequency of perineal tearing, 80% in outlet obstruction and 50% in emergency C-sections. Most of the observed effect was attributable to Type III FGM. Type I had relatively little effect, while Type II was intermediate.

But what about ethics?

In most cases, female genital mutilation is unquestionably more drastic and debilitating than male circumcision. For this reason, from a biological viewpoint, it is unjustifiable to imply that the two are equivalent. Nevertheless, the two kinds of injury of the external genitalia do share common ground with respect to ethical principles. As Brian Earp has argued, it is morally wrong to mutilate genitals in either sex prior to the age of consent. Yet, in many cases, FGM is performed on girls aged five or less. Similarly, male circumcision is often conducted quite soon after birth. It is open to discussion whether genital manipulation is permissible at any age, but doing so early in life surely violates an individual’s rights.

References

Abdulcadir, J., Catania, L., Hindin, M.J., Say, L., Petignat, P. & Abdulcadir, O. (2016) Female genital mutilation: A visual reference and learning tool for health care professionals. Obstetrics & Gynecology 128 :958-963.

Alsibiani, S.A. & Rouzi, A.A. (2010) Sexual function in women with female genital mutilation. Fertility & Sterility 93 :722-724.

Batha, E. (2016) The hidden cut: Female Genital Mutilation in Asia. Reuters
https://www.reuters.com/article/us-singapore-fgm-asia-factbox-idUSKCN12D04E

Earp, B.D. (2015) Female genital mutilation and male circumcision: Toward an autonomy-based ethical framework. Medicolegal Bioethics 5 :89-104.

Earp, B.D. (2017) Does female genital mutilation have health benefits? The problem with medicalizing morality. Quillette Magazine
http://quillette.com/2017/08/15/female-genital-mutilation-health-benefits-problem-medicalizing-morality/.

Gebremicheal, K., Alemseged, F., Ewunetu, H., Tolossa, D., Ma’alin, A., Yewondwessen, M. & Melaku, S. (2018) Sequela of female genital mutilation on birth outcomes in Jijiga town, Ethiopian Somali region: a prospective cohort study. BMC Pregnancy & Childbirth 18 :305:1-10.

Nussbaum, M. (1999) Sex and Social Justice. New York & Oxford: Oxford University Press.

Orchid Project (recommended for anyone seeking activenvolvement):
https://orchidproject.org/contact-us/

Sakeah, E., Debpuur, C., Oduro, A.R., Welaga, P., Aborigo, R., Sakeah, J.K. & Moyer, C.A. (2018) Prevalence and factors associated with female genital mutilation among women of reproductive age in the Bawku municipality and Pusiga District of northern Ghana. BMC Womens’ Health 18 ,150:1-10.

Sharfi, A.R., Elmegboul, M.A. & Abdella, A.A. (2013) The continuing challenge of female genital mutilation in Sudan. African Journal of Urology 19 :136-140.

United Nations Children's Fund. (2013) Female Genital Mutilation/Cutting: A Statistical Overview and Explorations of the Dynamics of Change. New York: UNICEF.

United Nations Children's Fund (2016) Female Genital Mutilation/Cutting: A Global Concern. (2-page pamphlet). New York: UNICEF.

WHO Study Group on Female Genital Mutilation and Obstetric Outcome (2006) Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet 367 :1835-1841.

World Health Organization (2018) Female Genital Mutilation (2-page pamphlet). Geneva: WHO.

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