Female genital mutilation

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"FGM" redirects here. For other uses, see FGM (disambiguation).
photograph
Road sign near Kapchorwa, Uganda, 2004.[1]
Definition Defined in 1997 by the WHO, UNICEF and UNFPA as the "partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons."[2]
Areas Most common in 27 countries in Africa, as well as in Yemen and Iraqi Kurdistan[3]
Numbers 125 million in those countries[4]
Age

Days after birth to puberty[5]

Female genital mutilation (FGM), also known as female genital cutting and female circumcision, is the ritual removal of some or all of the external female genitalia. Typically carried out by a traditional circumciser with a blade or razor, with or without anaesthesia, FGM is concentrated in 27 countries in Africa, as well as in Yemen and Iraqi Kurdistan, and practised to a lesser extent elsewhere in Asia and among diaspora communities around the world.[9] The age at which it is conducted varies from days after birth to puberty; in half the countries for which national figures are available, most girls are cut before the age of five.[10]

The procedures differ according to the ethnic group. They include removal of the clitoral hood and clitoris, and in the most severe form (known as infibulation) removal of the inner and outer labia and closure of the vulva; in this last procedure, a small hole is left for the passage of urine and menstrual blood, and the vagina is opened for intercourse and childbirth. Health effects depend on the procedure, but can include recurrent infections, chronic pain, cysts, an inability to get pregnant, complications during childbirth and fatal bleeding.[11] There are no known health benefits.[12]

The practice is rooted in gender inequality, attempts to control women's sexuality, and ideas about purity, modesty and aesthetics. It is usually initiated and carried out by women, who see it as a source of honour, and who fear that failing to have their daughters and granddaughters cut will expose the girls to social exclusion.[13] Over 125 million women and girls have experienced FGM in the 29 countries in which it is concentrated, and 30 million are at risk of being cut in those countries in the next decade.[4] Over eight million have been infibulated, a practice found largely in Djibouti, Eritrea, Somalia and Sudan.[14]

FGM has been outlawed or restricted in most of the countries in which it occurs, but the laws are poorly enforced.[15] There have been international efforts since the 1970s to persuade practitioners to abandon it, and in 2012 the United Nations General Assembly, recognizing FGM as a human-rights violation, voted unanimously to intensify those efforts.[16] The opposition is not without its critics, particularly among anthropologists. Eric Silverman writes that FGM has become one of anthropology's central moral topics, raising difficult questions about cultural relativism, tolerance and the universality of human rights.[17]

Terminology

English

photograph
Samburu FGM ceremony photographed by Louisa Kasdon, Laikipia plateau, Kenya, 2004[18]

Until the 1980s FGM was widely known as female circumcision, which implied an equivalence in severity with male circumcision.[19] In 1929 the Kenya Missionary Council began referring to it as the "sexual mutilation of women," following the lead of Marion Scott Stevenson, a Church of Scotland missionary.[20] References to it as mutilation increased throughout the 1970s.[21] Anthropologist Rose Oldfield Hayes used the term "female genital mutilation" in 1975 in the title of a paper, and in 1979 Austrian-American researcher Fran Hosken called it mutilation in her influential The Hosken Report: Genital and Sexual Mutilation of Females.[22]

The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children began calling it female genital mutilation in 1990, as did the World Health Organization (WHO) the following year.[23] In April 1997 the WHO, United Nations Children's Fund (UNICEF) and United Nations Population Fund (UNFPA) issued a "Joint Statement on Female Genital Mutilation," defining it 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."[24] Other terms include female genital cutting (FGC) and female genital mutilation/cutting (FGM/C), often used by those working with practitioners.[25]

Local terms

The many variants of FGM, which depend on the ethnic group and individual practitioner, are reflected in dozens of local terms in countries where it is common; women in Niger responded to a survey in 1998 using 50 different terms.[26] These often refer to purification. A common Arabic term for purification has the root t-h-r, used for male and female circumcision (tahur and tahara).[27] In the Bambara language, spoken mostly in Mali, FGM is known as bolokoli ("washing your hands") and in the Igbo language in Nigeria as isa aru ("having your bath").[28]

The mildest form (clitoridectomy) is widely known as sunna circumcision. Sunna means "tradition" in Arabic; within Islam it refers to the tradition of Muhammad, although the procedure is not a requirement.[29] A sunna kashfa in Sudan involves removing half the clitoris.[30] Nuss ("half") in Sudan is for anything between clitoridectomy and infibulation, and juwaniya ("the inside type") is where only the inner labia are sewn together.[31] In Somalia removal of the clitoris and inner labia is known as xalaalays or gudniin.[32] The term infibulation derives from fibula, Latin for clasp; the Ancient Romans reportedly fastened the foreskins or labia of male and female slaves with clasps to prevent sexual intercourse.[33] The surgical infibulation of women is known as pharaonic circumcision in Sudan, but as Sudanese circumcision in Egypt.[34] In Somalia it is known simply as qodob ("to sew up").[32]

Procedures, health effects

Circumcisers, methods

The procedures are generally performed by a traditional circumciser, with or without anaesthesia, often in the girl's home. The circumciser is usually an older woman who may be the local midwife; in communities where the male barber has assumed the role of health worker, he will perform FGM too.[35] In Egypt, Sudan and Kenya, FGM is carried out by health professionals; surveys in Egypt in 1997–2011 indicated that 77 percent of FGM procedures were performed by medical professionals, often physicians.[36]

When traditional circumcisers are involved, non-sterile cutting devices are likely to be used, including knives, razors, scissors, glass, sharpened rocks and fingernails.[37] A nurse in Uganda, quoted in 2007 in The Lancet, said a circumciser would use one knife to cut up to 30 girls at a time.[38] Cauterization is used in parts of Ethiopia.[39]

Depending on the involvement of healthcare professionals, the procedures may include a local or general anaesthetic, or neither. According to UNICEF in 2013, women in Egypt (where healthcare professionals are often involved) reported in 1995 that a local anaesthetic had been used on their daughters in 60 percent of cases, a general in 13 percent, and neither in 25 percent (two percent were missing/don't know).[40]

Classification

Overview

diagram
How FGM Types I–III differ from normal female anatomy

The procedures vary according to ethnicity and individual practitioners.[40] The difficulty of collecting accurate data across so many countries means that none of the typologies are entirely accurate. The aid agencies have created them based on household surveys known as Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) funded by the United States Agency for International Development (USAID) and the United Nations Children's Fund (UNICEF). These have been conducted in Africa roughly every five years, since 1984 and 1995 respectively. The questionnaires are completed by women aged 15–49.[41]

In one survey in Niger in 1998, the women responded with 50 different terms when asked what was done to them.[26] Translation problems are compounded by the women's confusion over which procedure they experienced. In a 2006 study in Sudan, in which over 500 women were asked to describe their procedure before being examined, a significant percentage of infibulated women reported a lesser procedure.[34]

UNICEF divides FGM into four categories: (1) cut, no flesh removed (pricking or symbolic circumcision); (2) cut, some flesh removed; (3) sewn closed; and (4) type not determined/unsure/doesn't know.[42] The WHO categorizes the main procedures as Types I–III, and Type IV for symbolic circumcision and miscellaneous procedures.[43]

WHO Types I–IV

Most women who undergo FGM experience Types I or II. Type I is further divided into Ia, the removal of the clitoral hood (rarely, if ever performed alone),[44] and the more common Ib (clitoridectomy), the partial or total removal of the clitoris and clitoral hood.[45] (When discussing FGM, the WHO uses "clitoris" to refer to the clitoral glans, the visible part of the clitoris.)[46] Susan Izett and Nahid Toubia write: "[T]he clitoris is held between the thumb and index finger, pulled out and amputated with one stroke of a sharp object."[47] Type II (excision) is the partial or total removal of the clitoris and inner labia, with or without removal of the outer labia. The term excision in French often refers to any form of FGM.[48]

Type III (infibulation) is the removal of all the external genitalia and the fusion of the wound. The inner and/or outer labia are cut away, with or without removal of the clitoris.[49] A single 2–5 mm-hole is left for the passage of urine and menstrual blood by inserting something, such as a twig, into the wound.[50] The vulva is closed with surgical thread, agave or acacia thorns, or a poultice (for example, made of raw egg, herbs and sugar). The girl's legs are tied together to help the tissue bond; the bindings are loosened after a week and usually removed after two.[51] The parts that have been removed might be placed in a pouch for the girl to wear.[52] Infibulated women and girls commonly experience difficulty emptying their bladders; in communities where infibulation is concentrated, this is regarded as normal and women might not associate their difficulties with the procedure.[53]

Comfort Momoh, a specialist midwife in England, describes an infibulation:

[E]lderly women, relatives and friends secure the girl in the lithotomy position. A deep incision is made rapidly on either side from the root of the clitoris to the fourchette, and a single cut of the razor excises the clitoris and both the labia majora and labia minora.

Bleeding is profuse, but is usually controlled by the application of various poultices, the threading of the edges of the skin with thorns, or clasping them between the edges of a split cane. A piece of twig is inserted between the edges of the skin to ensure ... [an opening] for urinary and menstrual flow. The lower limbs are then bound together for 2–6 weeks to promote haemostatis and encourage union of the two sides ... [As a result, the entrance to the vagina] is obliterated by a drum of skin extending across the orifice except for a small hole. Circumstances at the time may vary; the girl may struggle ferociously, in which case the incisions may become uncontrolled and haphazard. The girl may be pinned down so firmly that bones may fracture.[54]

More than eight million women in Africa, aged 15–49 years, have experienced infibulation, which is common in Djibouti, Eritrea, Somalia and Sudan.[14] The vulva is opened with a penis or knife for sexual intercourse. It is opened again for childbirth and repaired afterwards; this is known as defibulation (or deinfibulation) and reinfibulation.[55] There is also a procedure, known in Sudan known as El Adel, in which the vagina is cut again and tightened to mirror the size of the first infibulation. This is mostly performed after childbirth, but sometimes also before marriage and after divorce.[56]

Psychologist Hanny Lightfoot-Klein interviewed 300 Sudanese women and 100 men in the 1980s about sexual intercourse with Type III:

The penetration of the bride's infibulation takes anywhere from 3 or 4 days to several months. Some men are unable to penetrate their wives at all (in my study over 15%), and the task is often accomplished by a midwife under conditions of great secrecy, since this reflects negatively on the man's potency. Some who are unable to penetrate their wives manage to get them pregnant in spite of the infibulation, and the woman's vaginal passage is then cut open to allow birth to take place. ...

Those men who do manage to penetrate their wives do so often, or perhaps always, with the help of the "little knife." This creates a tear which they gradually rip more and more until the opening is sufficient to admit the penis. In some women, the scar tissue is so hardened and overgrown with keloidal formations that it can only be cut with very strong surgical scissors, as is reported by doctors who relate cases where they broke scalpels in the attempt.[57]

The WHO defines Type IV as "[a]ll other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization."[2] It includes nicking of the clitoris (symbolic circumcision), burning or scarring the genitals, and introducing substances into the vagina to tighten it.[58] A definition of FGM from the WHO in 1995 included gishiri cutting and angurya cutting; these were removed from the WHO's 2008 definition because of insufficient information about prevalence and consequences.[59] Gishiri cutting ("salt cut") involves cutting the vagina's front or back wall with a blade or penknife, performed in response to infertility, obstructed labour and several other conditions; over 30 percent of women with gishiri cuts in a study by Nigerian physician Mairo Usman Mandara had vesicovaginal fistuale. Angurya cutting is excision of the hymen, performed by the Hausa in Nigeria, usually seven days after birth.[60]

Labia stretching is also categorized as Type IV.[59] From the age of eight girls are encouraged to stretch their inner labia using sticks and massage, a practice common in southern and eastern Africa: Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Tanzania, Uganda and Zimbabwe. The practice is supposed to enhance sexual pleasure for the man and add to the sense of a woman as a closed space. Girls in Uganda are told they may have difficulty giving birth without stretched labia.[61]

Complications

photograph
Road sign in Bakau, Gambia, 2005. FGM is not illegal in Gambia, where 76 percent of women and girls have experienced it.[62]

FGM has no known health benefits.[12] It has immediate, short-term, and late complications, which depend on several factors: the type of FGM, the conditions in which the procedure took place and whether the practitioner had medical training, whether unsterilized or surgical single-use instruments were used, and whether surgical thread was used instead of agave or acacia thorns. Other factors include the availability of antibiotics, how small a hole was left for the passage of urine and menstrual blood, and whether the procedure was performed more than once (for example, to close an opening regarded as too wide or re-open one too small).[11]

Immediate complications include fatal bleeding, acute urinary retention, urinary infection, wound infection, septicemia, tetanus, and transmission of hepatitis or HIV if instruments are non-sterile or reused.[11] Because fatalities are rarely reported – few records are kept and complications may not be recognized – it is not known how many girls and women die.[63]

Short-term complications include necrotizing fasciitis (flesh-eating disease), delay in wound healing due to infection, endometritis, and hepatitis.[64] Late complications vary depending on the type of FGM performed.[11] The formation of scars, including keloids, can lead to strictures, obstruction or fistula formation of the urinary and genital tracts. Urinary-tract sequelae include damage to urethra and bladder, with infections and incontinence. Genital-tract sequelae include vaginal and pelvic infections, painful periods, pain during sexual intercourse, and infertility.[64] Complete obstruction of the vagina results in hematocolpos (where the vagina fills with menstrual blood) and hematometra (where blood is retained in the uterus).[11] Other complications include epidermoid cysts that may become infected, neuroma formation (growth of nerve tissue) involving nerves that supplied the clitoris, and pelvic pain.[65]

FGM ceremony in Indonesia
 — Stephanie Sinclair, The New York Times[66]

FGM may complicate pregnancy and place women at higher risk for obstetrical problems, which are more common with the more extensive FGM procedures.[11] Thus, in women with Type III who have developed vesicovaginal or rectovaginal fistulae (holes that allow urine or faeces to seep into the vagina), it is difficult to obtain clear urine samples as part of prenatal care, making the diagnosis of conditions such as pre-eclampsia harder.[64] Cervical evaluation during labour may be impeded and labour prolonged. Third-degree laceration, anal-sphincter damage and emergency caesarean section are more common in women who have experienced FGM.[11]

Neonatal mortality is also increased. The WHO estimated in 2006 that an additional 10–20 babies die per 1,000 deliveries as a result of FGM; the estimate was based on a study conducted on 28,393 women attending delivery wards at 28 obstetric centres in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan. In those settings all types of FGM were found to pose an increased risk of death to the baby: 15 percent higher for Type I, 32 percent for Type II and 55 percent for Type III.[67]

Psychological complications include depression and post-traumatic stress disorder.[37] In addition, feelings of shame and betrayal can develop when the women move outside their traditional circles and learn that their condition is not the norm.[11] They are more likely to report painful sexual intercourse and reduced sexual feelings.[68] A study in Saudi Arabia in 2010, based on interviews of 260 women, noted differences in arousal, lubrication and orgasm.[69] FGM does not necessarily destroy sexual desire; according to studies in the 1980s and 1990s, women said they were able to enjoy sex, though the risk of sexual dysfunction was higher with Type III.[70]

Prevalence

Overview

Percentage of women aged 15–49 who are living with FGM in the 29 countries in which it is concentrated (click here for a more detailed map of Africa).[71]
Percentage of women aged 15–49 who are living with FGM in the 29 countries in which it is concentrated (click here for a more detailed map of Africa).[71]

FGM is mostly found in what political scientist Gerry Mackie describes as an "intriguingly contiguous" zone in Africa – east to west from Somalia to Senegal, and north to south from Egypt to Tanzania.[72] With a population of around 167 million, Nigeria (prevalence 27 percent for 15–49 age group) has the highest number of women and girls who are living with FGM.[73] Around one-fifth of all cases are in Egypt (prevalence 91 percent for 15–49 age group).[74]

A 2013 UNICEF report based on 70 household surveys indicated that FGM is concentrated in 27 African countries, as well as in Yemen and Iraqi Kurdistan.[75] UNICEF estimates that 125 million women and girls in those 29 countries have been affected.[4] The report grouped the countries from very-high to very-low prevalence among women aged 15–49:[76]

A country's national prevalence may reflect a high prevalence among certain ethnicities, rather than a widespread practice.[77] For example, in Iraq it is found mostly among the Kurds in Erbil (58 percent sub-national prevalence in age group 15–49), Sulaymaniyah (54 percent) and Kirkuk (20 percent), giving the country a national prevalence of eight percent.[78] FGM is not invariably an ethnic marker, but can differ across national lines. In Guinea 99 percent of Fulani women have experienced it, against 12 percent of the Fulani in Chad, while in Nigeria the Fulani are the only large ethnic group in the country not to practise it.[79]

Ethnicity
 — UNICEF 2013[80]

In surveys conducted between 1997 and 2011, FGM was found to be more common in rural areas, less common in most countries among girls from the wealthiest homes, and (except in Sudan and Somalia) less common in girls whose mothers had access to primary or secondary/higher education. In Somalia and Sudan the situation was reversed: in Somalia the mothers' access to secondary/higher education was accompanied by a rise in prevalence of FGM in their daughters, and in Sudan access to any education was accompanied by a rise.[81]

Outside the 29 key countries, FGM has been documented in India, the United Arab Emirates, among the Bedouin in Israel, and reported by anecdote in Colombia, Congo, Oman, Peru and Sri Lanka.[82] It is practised in Jordan, Saudi Arabia, Indonesia and Malaysia, and exists within immigrant communities in Australia, New Zealand, Europe, Scandinavia, the United States and Canada.[83]

Type of FGM

Most women undergo Types I or II. Both procedures are performed in Egypt.[84] In Nigeria Type I is usually found in the south and the more severe forms in the north;[73] three percent of girls aged 0–14 in Nigeria had been infibulated as of 2013.[85] Type III is concentrated in northeastern Africa, particularly Djibouti, Eritrea, Somalia and Sudan.[86] In Djibouti, of women who had been cut as of 2006, 83 percent aged 45–49, and 42 percent aged 15–19, had undergone Type III. For the 15–49 group in Eritrea, the figure was 38 percent in 2002, and in Somalia 63 percent in 2006.[87] The type of procedure is linked to ethnicity. A 2002 survey in Eritrea found that all Hedareb girls had been infibulated, compared to two percent of the Tigrinya, most of whom fell into UNICEF's "cut, no flesh removed" category.[88]

Age conducted

Age range
 — UNICEF 2013[5]

FGM is mostly performed from shortly after birth to age 15.[5] The variation signals that the practice is often not a rite of passage between childhood and adulthood.[89]

In half the countries for which national figures were available in 2000–2010, most girls had been cut by the age of five. Over 80 percent of girls who experience FGM are cut before that age in Nigeria, Mali, Eritrea, Ghana and Mauritania. The percentage is reversed in Somalia, Egypt, Chad and the Central African Republic, where over 80 percent of those cut are cut between five and 14.[10] A 1997 survey found that 76 percent of girls in Yemen had been cut within two weeks of birth.[90] Just as the type of FGM is linked to ethnicity, so is the mean age; in Kenya, for example, the Kisi cut around age 10 and the Kamba at 16.[91]

Decline

In 2013 UNICEF reported a downward trend in over half the 29 key countries in the 15–19 cohort compared to women aged 45–49.[93] They wrote in July 2014 that the likelihood of a girl experiencing FGM is overall one third lower than it was three decades ago.[94]

In Kenya and Tanzania, women aged 45–49 years were found to be three times more likely to have been cut than the 15–19 cohort (a drop in Kenya from 49 to 15 percent, and in Tanzania from 22 to 7 percent). In Benin, Central African Republic, Iraq, Liberia and Nigeria the figure for the 15–19 group had dropped by about half. Prevalence rates in Chad, Djibouti, Gambia, Guinea-Bissau, Mali, Senegal, Somalia, Sudan and Yemen remained roughly the same.[95] If the current rate of decline continues, the number of women and girls affected by FGM in those 29 countries will increase, because of population growth, from 125 million to 196 million by 2050.[94]

Prevalence among the 0–14 age group, as reported by their mothers (data from UNICEF 2014)[6]
Prevalence among the 0–14 age group, as reported by their mothers (data from UNICEF 2014)[6]

Women who respond to surveys on FGM are reporting events experienced years ago; the time lag means that prevalence figures do not reflect trends in the youngest group.[96] UNICEF bases its figures on the 15–49 cohort, because it regards uncut girls as at risk until they are 14.[97] An additional complication is that, in countries with campaigns against FGM, women may choose not to report that their daughters have been cut.[98]

Women in 18 countries were asked about the FGM status of their daughters aged 0–14. According to UNICEF in 2014, the surveys showed a prevalence of 0.3 percent in Benin at the lowest (7 percent for the 15–49 group) to 56 percent in Gambia (76 percent for 15–49).[6]

In a study in Egypt in 2008–2010 (FGM was banned there by decree in 2007 and criminalized in 2008), 4,158 women and girls aged 5–25, who presented to three departments at Sohag and Qena University Hospitals, replied to an oral questionnaire about FGM, along with their parents. According to the researchers, the most common form of FGM in Egypt is Type I. The study found that, between 2000 and 2009, 3,711 of the subjects had undergone FGM, giving a prevalence rate of 89.2 percent. The incidence rate was 9.6 percent in 2000. It began to fall in 2006, and by 2009 had declined to 7.7 percent. After 2007 most of the procedures were conducted by general practitioners; the researchers suggested that the criminalization of FGM had deterred gynaecologists, so general practitioners were doing it instead.[99]

Reasons

Overview

Practitioners see the rituals as marking community and gender boundaries, "shaping and defining feminine sexuality and gender, aesthetics, tradition, and religiosity," writes anthropologist Rogaia Mustafa Abusharaf.[100] Gerry Mackie compares FGM to footbinding (outlawed in China in 1911): an ethnic marker carried out on young girls, nearly universal where practised, tied to ideas about honour, appropriate marriage, health, fertility and aesthetics, and supported by women.[101]

The most common reasons for FGM cited in surveys include social acceptance, hygiene, preservation of virginity, marriageability, enhancement of male sexual pleasure, and religion.[102] Several myths contribute to its continuance, including that it controls genital discharges, aids conception and birth, that an uncut clitoris will keep growing, and that the clitoris will harm a baby if it comes into contact with the baby's head.[103] A more practical reason is that circumcisers rely on it for their living.[104]

The primary sexual motivations vary. Anika Rahman and Nahid Toubia write that the focus in Egypt, Sudan and Somalia is on curbing premarital sex, and in Kenya and Uganda on reducing women's sexual desire so that men can take several wives.[105] Infibulation may enhance male sexual pleasure; Gruenbaum writes that men appear to enjoy the effort of penetrating it.[106] In parts of Asia and Africa men appear to prefer women's genitals to be dry (commentators have described this preference in central and southern Africa), and women regularly introduce substances into the vagina to achieve it, including leaves, tree bark, toothpaste and Vicks menthol rub.[107] The WHO includes this practice as Type IV FGM; the added friction during intercourse can cause lacerations and increase the risk of infection.[108]

Support from women

photograph
Molly Melching of Tostan in 2007, celebrating the 10th anniversary of the abandonment of FGM by Malicounda Bambara, Senegal

Dahabo Musa, a Somali woman, described infibulation in a 1988 poem as the "three feminine sorrows": the procedure itself, the wedding night when the woman is cut open, then childbirth when she is cut again.[109] Despite the evident suffering, it is women who organize it. Anthropologist Rose Oldfield Hayes wrote in 1975 that educated Sudanese men living in cities who did not want their daughters to be infibulated (preferring clitoridectomy) would find the girls had been sewn up after their grandmothers arranged a visit to relatives.[110]

In a 1982 study in Sudan, only 17.4 percent of 3,210 women opposed FGM, and most preferred excision and infibulation over clitoridectomy.[111] Attitudes are slowly changing. In 1989–1990 in Sudan, 79 percent of women said the practice should continue, a figure reduced to 48 percent in 2010. Over 50 percent of women in Mali, Guinea, Sierra Leone, Somalia, Gambia and Egypt support FGM's continuance, but elsewhere in Africa, Iraq and Yemen, most say it should end or are unsure.[112]

Anthropologist Fadwa El Guindi argues that FGM is not a matter of male control, and is not intended to appeal to men. Male circumcision is viewed in Africa as defeminizing men and FGM as demasculinizing women. Removing the clitoris is chosen by women for women, she maintains, to reduce sexuality before marriage and enhance it afterwards; she argues that the reduction in sexual desire is usually temporary.[113]

Fuambai Ahmadu, an anthropologist and member of the Kono people of Sierra Leone, chose to be cut as a 22-year-old during a Sande society initiation. She argues that the negative effects of clitoridectomy and excision are exaggerated. There is a male-centred assumption, in Ahmadu's view, that the clitoris is an integral part of a woman's sexuality, but "female excision ... is a negation of the masculine," she writes. African female symbolism revolves instead around the concept of the womb.[114] Excision and infibulation draw on that idea of enclosure, confinement, privacy and fertility.[115]

Against this, UNICEF and other UN bodies have identified FGM as a "self-enforcing social convention": "There is a social obligation to conform to the practice and a widespread belief that if [families] do not, they are likely to pay a price that could include social exclusion, criticism, ridicule, stigma or the inability to find their daughters suitable marriage partners."[116] Uncut women are viewed as dirty and unmarriageable; UNICEF reported in 1995 that in Tanzania the Masai would not call an uncut woman "mother" when she had children.[117] Because of poor access to information, and because the circumcisers downplay the causal connection, women may not associate the health consequences with the procedure. Lala Baldé, president of a women's association in Medina Cherif, a village in Senegal, told Mackie in 1998 that when girls fell ill or died, it was attributed to evil spirits. When informed of the causal relationship, Mackie writes, the women broke down and wept. He argues that surveys taken before and after this sharing of information would show very different levels of support for FGM.[118]

Mackie has worked with UNICEF to develop programmes in which whole villages pledge to leave their daughters uncut and allow their sons to marry uncut girls.[119] The American non-profit group Tostan, founded by Molly Melching in 1991, has used this model successfully, introducing community empowerment programmes that focus on healthcare and local democracy.[120] In 1997, using the Tostan programme, Malicounda Bambara in Senegal became the first village to abandon FGM, and by 2014 over 7,000 communities in eight countries had pledged to abandon both FGM and child marriage.[121] A UNFPA-UNICEF joint programme, underway in 15 African countries as of 2014, is modelled along similar lines.[116]

Religion

Surveys have shown a widespread belief, particularly in Mali, Eritrea, Mauritania, Guinea and Egypt, that FGM is a religious requirement.[122] Gerry Mackie and John LeJeune write that practitioners may not distinguish between religion, tradition and chastity, making it difficult to interpret the data.[123] As part of a UNFPA–UNICEF joint programme to end FGM, 20,941 religious and traditional leaders made public declarations between 2008 and 2013 delinking their religions from the practice, and religious leaders issued 2,898 edicts against it. [124]

Mackie writes that FGM is found "only in or adjacent to" Islamic groups.[125] There is no mention of it in the Quran. It is praised in several hadith (sayings attributed to Muhammad) as noble but not required, along with advice that the milder forms are kinder to women.[126] Although its origins are pre-Islamic, FGM became associated with Islam because of that religion's focus on female chastity and seclusion.[127] In 2007 the Al-Azhar Supreme Council of Islamic Research in Cairo ruled, according to UNICEF, that FGM had "no basis in core Islamic law or any of its partial provisions."[128] Several fatwas were issued against the practice between 2008 and 2013.[124]

FGM is also practised by animist groups, particularly in Guinea and Mali, and by Christians.[129] In Niger, for example, 55 percent of Christian women and girls have experienced FGM, compared with two percent of their Muslim counterparts.[130] There is no mention of FGM in the Bible, and Christian missionaries in Africa were among the first to object to it.[131] The only Jewish group known to have practised it are the Beta Israel of Ethiopia; Judaism requires male circumcision, but does not allow FGM.[132]

History

Antiquity

Spell 1117

But if a man wants to know how to live, he should recite it [a magical spell] every day, after his flesh has been rubbed with the b3d [unknown substance] of an uncircumcised girl ['m't] and the flakes of skin [šnft] of an uncircumcised bald man.

— Inscription on Egyptian sarcophagus, c. 1991–1786 BCE[133]

The origins of the practice are unknown.[134] Gerry Mackie has suggested that it began with the Meroite civilization in present-day Sudan; he writes that its east-west, north-south contiguous distribution in Africa intersects in Sudan, and speculates that infibulation originated there with imperial polygyny, before the rise of Islam, to increase confidence in paternity.[135]

Historian Mary Knight writes that there may be a reference to an uncircumcised girl ('m't), written in hieroglyphs, in what is known as Spell 1117 of the Coffin Texts:

a m a
X1
D53 B1

The spell was found on the sarcophagus of Sit-hedjhotep, now in the Egyptian Museum, and dates to Egypt's Middle Kingdom, c. 1991–1786 BCE.[136] (Paul F. O'Rourke argues that 'm't probably refers instead to a menstruating woman.)[137] The proposed circumcision of an Egyptian girl, Tathemis, is mentioned on a Greek papyrus from 163 BCE in the British Museum:

Sometime after this, Nephoris [Tathemis's mother] defrauded me, being anxious that it was time for Tathemis to be circumcised, as is the custom among the Egyptians. She asked that I give her 1,300 drachmae ... to clothe her ... and to provide her with a marriage dowry ... if she didn't do each of these or if she did not circumcise Tathemis in the month of Mecheir, year 18 [163 BCE], she would repay me 2,400 drachmae on the spot.[138]

The examination of mummies has shown no evidence of FGM. Citing the Australian pathologist Grafton Elliot Smith, who examined hundreds of mummies in the early 20th century, Knight writes that the genital area may resemble Type III, because during mummification the skin of the outer labia was pulled toward the anus to cover the pudendal cleft, possibly to prevent sexual violation. It was similarly not possible to determine whether Types I or II had been performed, because soft tissues had been removed by the embalmers or had deteriorated.[139]

This is one of the customs most zealously pursued by them [the Egyptians]: to raise every child that is born and to circumcise [peritemnein] the males and excise [ektemnein] the females ...

Strabo, Geographica, c. 25 BCE.[140]

The Greek geographer Strabo (c. 64 BCE – c. 23 CE) wrote about FGM after visiting Egypt around 25 BCE (right).[140] The philosopher Philo of Alexandria (c. 20 BCE – 50 CE) also made reference to it: "the Egyptians by the custom of their country circumcise the marriageable youth and maid in the fourteenth (year) of their age, when the male begins to get seed, and the female to have a menstrual flow."[141] It is mentioned briefly in a work attributed to the Greek physician Galen (129 – c. 200 CE): "When [the clitoris] sticks out to a great extent in their young women, Egyptians consider it appropriate to cut it out."[142]

Another Greek physician, Aëtius of Amida (mid-5th to mid-6th century CE), offered more detail in book 16 of his Sixteen Books on Medicine, citing the physician Philomenes. The procedure was performed in case the clitoris, or nymphê, grew too large or triggered sexual desire when rubbing against clothing. "On this account, it seemed proper to the Egyptians to remove it before it became greatly enlarged," Aëtius wrote, "especially at that time when the girls were about to be married":

The surgery is performed in this way: Have the girl sit on a chair while a muscled young man standing behind her places his arms below the girl's thighs. Have him separate and steady her legs and whole body. Standing in front and taking hold of the clitoris with a broad-mouthed forceps in his left hand, the surgeon stretches it outward, while with the right hand, he cuts it off at the point next to the pincers of the forceps.

It is proper to let a length remain from that cut off, about the size of the membrane that's between the nostrils, so as to take away the excess material only; as I have said, the part to be removed is at that point just above the pincers of the forceps. Because the clitoris is a skinlike structure and stretches out excessively, do not cut off too much, as a urinary fistula may result from cutting such large growths too deeply.[143]

The genital area was then cleaned with a sponge, frankincense powder and wine or cold water, and wrapped in linen bandages dipped in vinegar until the seventh day, when calamine, rose petals, date pits or a "genital powder made from baked clay" might be spread on the wound.[143]

Whatever the practice's origins, infibulation became linked to slavery.[144] Mackie cites the Portuguese missionary João dos Santos, who in 1609 wrote of a group inland from Mogadishu who had a "custome to sew up their Females, especially their slaves being young to make them unable for conception, which makes these slaves sell dearer, both for their chastitie, and for better confidence which their Masters put in them."[145] The English explorer William Browne wrote in 1799 that the Egyptians practised excision, and that slaves in that country were infibulated to prevent pregnancy.[146] Thus, Mackie argues, a "practice associated with shameful female slavery came to stand for honor."[147]

Europe and the United States

portrait
Isaac Baker Brown "set to work to remove the clitoris whenever he had the opportunity of doing so."[148]

Gynaecologists in 19th-century Europe and the United States removed the clitoris to treat insanity and masturbation.[149] British doctor Robert Thomas suggested clitoridectomy as a cure for nymphomania in 1813.[150] One of the first reported clitoridectomies in the West was performed in 1822 in Berlin by Karl Ferdinand von Graefe; the patient was a teenage girl regarded as an "imbecile" who was masturbating.[151]

Isaac Baker Brown, an English gynaecologist, president of the Medical Society of London, and co-founder in 1845 of St. Mary's Hospital in London, believed that masturbation, or "unnatural irritation" of the clitoris, caused epilepsy, hysteria, mania and idiocy, and "set to work to remove [it] whenever he had the opportunity of doing so," according to his obituary in the Medical Times and Gazette.[148]

Brown performed several clitoridectomies between 1859 and 1866. When he published his views in On the Curability of Certain Forms of Insanity, Epilepsy, Catalepsy, and Hysteria in Females (1866), doctors in London accused him of quackery and expelled him from the Obstetrical Society.[152]

In the United States J. Marion Sims followed Brown's work, and in 1862 slit the neck of a woman's uterus and amputated her clitoris, "for the relief of the nervous or hysterical condition as recommended by Baker Brown," after the patient had complained of period pain, convulsions and bladder problems.[153] G. J. Barker-Benfield writes that clitoridectomy continued in the US until at least 1904 and perhaps into the 1920s.[154] According to a 1985 paper in the Obstetrical & Gynecological Survey, it was performed in the US into the 1960s to treat hysteria, erotomania and lesbianism.[155]

Opposition

Colonial opposition in Kenya

Muthirigu

Little knives in their sheaths
That they may fight with the church,
The time has come.
Elders (of the church)
When Kenyatta comes
You will be given women's clothes
And you will have to cook him his food.

— from the Muthirigu (1929),
Kikuyu dance-songs
protesting church opposition to FGM[156]

Protestant missionaries in British East Africa (present-day Kenya), began campaigning against FGM in the early 20th century when Dr. John Arthur joined the Church of Scotland Mission (CSM) in Kikuyu. The practice was known by the Kikuyu, the country's main ethnic group, as irua for both girls and boys, and involved excision (Type II) for girls and removal of the foreskin for boys. It was an important ethnic marker, and unexcised Kikuyu women, known as irugu, were outcasts.[157]

photograph
American missionary Hulda Stumpf was murdered in Kikuyu in 1930 after opposing FGM.

Jomo Kenyatta, general secretary of the Kikuyu Central Association and Kenya's first prime minister from 1963, wrote in 1938 that, for the Kikuyu, the institution of FGM was the "conditio sine qua non of the whole teaching of tribal law, religion and morality." No proper Kikuyu man or woman would marry or have sexual relations with someone who was not circumcised. A woman's responsibilities toward the tribe began with her initiation; her age and place within tribal history was traced to that day, and the group of girls with whom she was cut was named according to current events, an oral tradition that allowed the Kikuyu to track people and events going back hundreds of years.[158]

From 1925, beginning with the CSM mission, several missionary churches declared that FGM was prohibited for African Christians. The CSM announced that Africans practising it would be excommunicated, resulting in hundreds leaving or being expelled.[159] The stand-off turned FGM into a focal point of the Kenyan independence movement; the 1929–1931 period is known in the country's historiography as the female circumcision controversy.[160]

In 1929 the Kenya Missionary Council began referring to FGM as the "sexual mutilation of women," rather than circumcision, and a person's stance toward the practice became a test of loyalty, either to the Christian churches or the Kikuyu Central Association.[161] Hulda Stumpf, an American missionary with the Africa Inland Mission who opposed FGM in the girls' school she helped to run, was murdered in 1930 after apparently being circumcised by her attacker.[162]

In 1956 the council of male elders (the Njuri Nchecke) in Meru announced a ban on FGM. Over the next three years, as a symbol of defiance, thousands of girls cut each other's genitals with razor blades. The movement came to be known in Meru as Ngaitana ("I will circumcise myself"), because to avoid naming their friends the girls said they had cut themselves. Historian Lynn Thomas describes the episode as significant in the history of FGM because it made clear that its victims were also its perpetrators.[163]

Growth of opposition

photograph
Nawal El Saadawi was one of the first African feminists to criticize FGM.

The first known non-colonial campaign against FGM began in Egypt in the 1920s, when the Egyptian Doctors' Society called for a ban.[164] There was a parallel campaign in Sudan, run by religious leaders and British women; infibulation was banned there in 1946, but the law was unpopular and barely enforced.[165] The Egyptian government banned infibulation in state-run hospitals in 1959, but allowed partial clitoridectomy if parents requested it.[166] The UN asked the WHO to investigate FGM that year, but the latter responded that it was not a medical issue.[167]

Feminists took up the issue throughout the 1970s.[168] Egyptian physician Nawal El Saadawi's book, Women and Sex (1972), criticized FGM; the book was banned in Egypt and El Saadawi lost her job as director general of public health.[169] She followed up with a chapter, "The Circumcision of Girls," in The Hidden Face of Eve: Women in the Arab World (1980), which described her own clitoridectomy when she was six years old:

I did not know what they had cut off from my body, and I did not try to find out. I just wept, and called out to my mother for help. But the worst shock of all was when I looked around and found her standing by my side. Yes, it was her, I could not be mistaken, in flesh and blood, right in the midst of these strangers, talking to them and smiling at them, as though they had not participated in slaughtering her daughter just a few moments ago.[170]

In 1975 the American social scientist Rose Oldfield Hayes became the first female academic to publish a detailed account of FGM, aided by her ability to discuss the issues directly with women in Sudan. Her article in American Ethnologist called it "female genital mutilation," and brought it to wider academic attention.[171]

Four years later Austrian-American feminist Fran Hosken published The Hosken Report: Genital and Sexual Mutilation of Females (1979), the first to estimate the global number of women cut. She wrote that 110,529,000 women in 20 African countries had experienced it.[172] The figures were speculative, but in several instances consistent with later surveys; Mackie writes that her work was "more informative than the silence that preceded her efforts."[173]

Describing FGM as a "training ground for male violence," Hosken accused female practitioners of "participating in the destruction of their own kind."[174] The language caused a rift between Western and African feminists; African women boycotted a session featuring Hosken during the UN's Mid-Decade Conference on Women in Copenhagen in July 1980.[175]

The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, founded after a seminar in Dakar, Senegal, in 1984, called for an end to the practice, as did the UN's World Conference on Human Rights in Vienna in June 1993. The conference listed FGM as a form of violence against women, marking it as a human-rights violation, rather than a medical issue. In December 1993 the UN General Assembly adopted the Declaration on the Elimination of Violence Against Women, which included FGM.[176] Throughout the 1990s and 2000s African governments banned or restricted it. In July 2003 the African Union ratified the Maputo Protocol on the rights of women, article 5 of which supports the elimination of harmful practices, including FGM.[177] By 2013 laws had been passed in 22 of the 27 African countries in which FGM is concentrated, though several fell short of a ban.[178]

Egypt finally outlawed FGM in 2008 after at least two partial bans. Two incidents had attracted international attention. In 1994 CNN broadcast images of a child undergoing FGM in a barber's shop in Cairo, and in 2007 a child died during an FGM procedure. The death prompted the Al-Azhar Supreme Council of Islamic Research, the country's highest religious authority, to rule that FGM had no basis in Islamic law, and the government banned it in July 2007 by ministerial decree. Conducting FGM was added as a criminal offence to the country's penal code in June 2008.[179] The first charges under the new law were laid in 2014 after a girl died; a doctor was charged with manslaughter and the girl's father with complicity.[180]

United Nations

The United Nations General Assembly included FGM in resolution 48/104, the Declaration on the Elimination of Violence Against Women, in December 1993,[181] and in 2003 the UN began sponsoring an International Day of Zero Tolerance to Female Genital Mutilation every 6 February.[182] In December 2012 the General Assembly passed resolution 67/146, "Intensifying global efforts for the elimination of female genital mutilations," recognizing FGM as an "irreparable, irreversible abuse that impacts negatively on the human rights of women and girls."[16]

UNFPA and UNICEF launched a joint programme in 2007 with the aim of reducing FGM by 40 percent within the 0–15 age group, and eliminating it entirely from at least one country. Fifteen countries joined the programme: Djibouti, Egypt, Ethiopia, Guinea, Guinea-Bissau, Kenya, Senegal and Sudan in 2008; Burkina Faso, Gambia, Uganda and Somalia in 2009; and Eritrea, Mali and Mauritania in 2011.[183] Phase 1 lasted from 2008 to 2013, with a budget of $37 million, over $20 million of it donated by Norway.[184] Phase 2 extends the programme from 2014 to 2017.[185]

By 2013 the programme had organized public declarations of abandonment in 12,753 communities, integrated FGM prevention into pre- and postnatal care in 5,571 health facilities, and trained over 100,000 doctors, nurses and midwives in FGM care and prevention. The programme helped to create alternative rites of passage in Uganda and Kenya, and in Sudan supported the (pre-existing) Saleema initiative. Saleema means "whole" in Arabic; the initiative promotes the term as a desirable description of an uncut woman.[186] The programme noted that anti-FGM law enforcement is weak, and that, even where arrests are made, prosecution may fail because of inadequate collection of evidence.[187] It therefore supported the training of 3011 personnel in eight countries (Djibouti, Eritrea, Ethiopia, Guinea, Guinea-Bissau, Kenya, Senegal and Uganda) in how to enforce the laws, and sponsored campaigns to raise awareness of them.[188]

Non-practising countries

As a result of immigration, the practice spread to Australia, Europe, North America and Scandinavia.[189] As of 2013 anti-FGM legislation had been passed by 33 countries outside Africa and the Middle East.[8] Sweden banned it in 1982, the first Western country to do so.[190] Several former colonial powers, including Belgium, Britain, France and the Netherlands, followed suit, either with new laws or by making clear that FGM was covered by existing legislation.[191] It is banned or restricted in Australia, New Zealand, the European Union, the United States and Canada.[192]

photograph
Efua Dorkenoo (1949–2014), author of Cutting the Rose (1994) and founder of FORWARD, received an OBE in 1994 for her work against FGM in the UK.[193]

Canada recognized FGM as a form of persecution in July 1994, when it granted refugee status to Khadra Hassan Farah, who had fled Somalia to avoid her daughter being cut.[194] FGM is outlawed by section 268 of the Criminal Code of Canada unless "the person is at least eighteen years of age and there is no resulting bodily harm."[195] As of May 2012 there had been no prosecutions.[196]

In France over 100 parents and two practitioners had been prosecuted by 2012; FGM is covered by a provision of the country's penal code dealing with violence against children.[197] Children under six undergo medical examinations that include examination of the genitals, and doctors are obliged to report FGM.[198] Up to 30,000 women in France are thought to have experienced it.[199] Colette Gallard, a family-planning counsellor, writes that when FGM was first encountered there, the reaction was that Westerners ought not to intervene, and it took the deaths of two girls in 1982, one of them three months old, for that attitude to change.[200] The first civil suit was in 1982 and the first criminal prosecution in 1993.[201] In 1999 a woman was sentenced to eight years' imprisonment for having performed FGM on 48 girls.[202]

Around 137,000 women and girls living as permanent residents in England and Wales in 2011 were born in countries where FGM is practised, according to a 2014 report by epidemiologist Alison Macfarlane and Efua Dorkenoo.[203] It is an offence in the UK under the Prohibition of Female Circumcision Act 1985 to perform FGM on children or adults, and an offence under the Female Genital Mutilation Act 2003 and Prohibition of Female Genital Mutilation (Scotland) Act 2005 to arrange it outside the country for British citizens or permanent residents.[204] The United Nations Committee on the Elimination of Discrimination against Women expressed concern in 2013 that there had been no convictions in the UK.[205] The first charges were brought in March 2014, against a physician and another man, after the physician repaired the infibulation of a woman in London who had given birth.[206]

In the United States the Centers for Disease Control estimated in 1997 that 168,000 girls living there in 1990 had undergone FGM or were at risk.[207] A Nigerian woman successfully contested deportation in March 1994 on the grounds that her daughters might be cut, and in 1996 Fauziya Kasinga from Togo became the first to be granted asylum to escape FGM.[208] In September that year the Illegal Immigration Reform and Immigrant Responsibility Act made it illegal to perform FGM on minors for non-medical reasons, and in 2013 the Transport for Female Genital Mutilation Act prohibited transporting a minor out of the country for the purpose of FGM.[209] The American Academy of Pediatrics opposes all forms of FGM. In 2010 it briefly suggested in a policy statement that ceremonial "pricking or incising the clitoral skin" was a harmless procedure that might satisfy parents, but it withdrew the statement after complaints.[210] The first FGM conviction in the United States was in 2006, when Khalid Adem, who had emigrated from Ethiopia, was sentenced to ten years after severing his two-year-old daughter's clitoris with a pair of scissors.[211]

Criticism of opposition

Tolerance versus human rights

photograph
Novelist Alice Walker, who criticized FGM in Possessing the Secret of Joy (1992) and Warrior Marks (1993), was accused of portraying Africa as a "Hobbesian place of savage brutality," writes Silverman.[212]

Anthropologist Eric Silverman wrote in 2004 that FGM had "emerged as one of the central moral topics of contemporary anthropology." Anthropologists have accused FGM eradicationists of cultural colonialism; in turn, the former have been criticized for their moral relativism and failure to defend the idea of universal human rights.[213]

The biological reductionism of the eradicationists, according to the argument, undermines the agency of the practitioners and serves to "other" them, in particular by calling African parents mutilators.[214] Feminist theorist Obioma Nnaemeka – herself strongly opposed to FGM ("If one is circumcised, it is one too many") – argues that the power of renaming it female genital mutilation cannot be underestimated:

In this name game, although the discussion is about African women, a subtext of barbaric African and Muslim cultures and the West's relevance (even indispensability) in purging the barbarism marks another era where colonialism and missionary zeal determined what "civilization" was, and figured out how and when to force it on people who did not ask for it.[215]

Ugandan law professor Sylvia Tamale argues that early Western opposition to FGM stemmed from a Judeo-Christian judgment that African sexual and family practices – including dry sex, polygyny, bride price and levirate marriage – were primitive and required correction.[216] Yet Africans who object to the opposition to FGM risk appearing to defend the practice.[217] African feminists "do not condone the negative aspects of the practice," writes Tamale, but "take strong exception to the imperialist, racist and dehumanising infantilization of African women."[216]

The debate has highlighted a tension between anthropology and feminism, with the former's focus on tolerance and the latter's on equal rights for all women. Anthropologist Christine Walley writes that a common trope in the anti-FGM literature has been to present African women as victims of false consciousness participating in their own oppression and destruction, a position promoted by several feminists in the 1970s, including Fran Hosken and Mary Daly. It prompted the French Association of Anthropologists to issue a statement in 1981, at the height of the early debates, that "a certain feminism resuscitates (today) the moralistic arrogance of yesterday's colonialism."[218]

1996 Pulitzer Prize for Feature Photography

A series of 13 photographs of an FGM ceremony in Kenya won the award:
Photograph 10
Photograph 13

 — Stephanie Walsh, Newhouse News Service[219]

As an example of the disrespect arguably shown to women who have undergone FGM, commentators highlight the appropriation of the women's bodies as exhibits. Historian Chima Korieh cites the publication in 1996 of the Pulitzer-prize-winning photographs of a 16-year-old Kenyan girl undergoing FGM. The photographs were published by 12 American newspapers, but, according to Korieh, the girl had not given permission for the images to be taken, much less published.[220]

Whether FGM is invariably harmful is also disputed. Anthropologist Richard Shweder argues that the medical evidence does not support that it is; he cites reviews of the medical literature by epidemiologist Carla Obermeyer, who suggested in 1999, 2003 and 2005 that serious complications were the exception.[221] Gerry Mackie disputed Obermeyer's findings, arguing that she had exaggerated the claims of the medical literature before dismissing them (by, for example, wrongly portraying the opposition as arguing that FGM invariably destroys sexual pleasure, or inevitably leads to death or serious illness).[222] Shweder also cites a 2001 study by Linda Morison of the London School of Hygiene and Tropical Medicine that looked at the reproductive health consequences of Type II FGM in the Gambia; Morison concluded that there were few differences between the circumcised and uncircumcised women.[223]

Comparison with other procedures

Obioma Nnaemeka argues that the crucial question, broader than FGM, is why the female body is subjected to so much "abuse and indignity" around the world, including in the West.[224] Several authors have drawn a parallel between FGM and cosmetic procedures.[225] Ronán Conroy of the Royal College of Surgeons in Ireland wrote in 2006 that cosmetic genital procedures were "driving the advance of female genital mutilation" by encouraging women to see natural variations as defects.[226] Anthropologist Fadwa El Guindi compares FGM to breast enhancement, in which the maternal function of the breast becomes secondary to men's sexual pleasure; breast enhancement could be called breast mutilation, she writes, particularly when the nipples lose sensation because of implants.[227] Benoîte Groult made a similar point in 1975, citing FGM and cosmetic surgery as sexist and patriarchal.[228]

photograph
Martha Nussbaum argues that the key moral and legal issue with FGM is that it is mostly conducted on children using physical force.

Carla Obermeyer maintains that FGM may be conducive to women's well-being within their communities in the same way that rhinoplasty and male circumcision may help people elsewhere.[229] The WHO does not include procedures such as labiaplasty, vaginoplasty and clitoral hood reduction as examples of FGM; several elective practices do fall within its categories, but its definition aims to avoid loopholes.[230] Some of the laws banning FGM would seem to cover cosmetic procedures. Sweden, for example, has banned operations "on the external female genital organs which are designed to mutilate them or produce other permanent changes in them" regardless of consent.[231] Gynaecologist Birgitta Essén and anthropologist Sara Johnsdotter note that it seems the law distinguishes between Western and African genitals, and deems only African women (such as those seeking reinfibulation after childbirth) unfit to make their own decisions.[232]

Arguing against these parallels, philosopher Martha Nussbaum writes that the key issue is that FGM is mostly conducted on children using physical force. She argues that the distinction between social pressure and physical force is always morally and legally salient, comparable to the distinction between seduction and rape. She argues further that the literacy of women in practising countries is generally poorer than in the Western world, and that this reduces their ability to make informed choices.[233]

Several commentators maintain that children's rights are violated with the genital alteration of intersex children, who are born with anomalies that physicians choose to correct. Legal scholars Nancy Ehrenreich and Mark Barr write that thousands of these procedures take place every year in the United States, and say that they are medically unnecessary, more extensive than FGM, and have more serious physical and mental consequences. They attribute the silence of anti-FGM campaigners about intersex procedures to white privilege and a refusal to acknowledge that "similar unnecessary and harmful genital cutting occurs in their own backyards."[234]

Sources

  1. ^ FGM was outlawed in Uganda in 2010, which has a national prevalence of one percent; see "Uganda: Statistical profile on female genital mutilation/cutting", UNICEF, January 2014.

    FGM is practised there by the Pokot, Sabiny and Tepeth people. See Andrew Masinde, "FGM: Despite the ban, the monster still rears its ugly head in Uganda", New Vision, Uganda, 5 February 2013.

  2. ^ a b "Classification of female genital mutilation", World Health Organization, 2014.
  3. ^ Claudia Capper, et al, Female Genital Mutilation/Cutting: A Statistical Overview and Exploration of the Dynamics of Change, United Nations Children's Fund, July 2013 (hereafter UNICEF 2013), pp. 5, 9, 26–27.
  4. ^ a b c UNICEF 2013, p. 22: "More than 125 million girls and women alive today have been cut in the 29 countries in Africa and the Middle East where FGM/C is concentrated."

    UNICEF 2013, p. 114: "Another 30 million girls are at risk of being cut in the next decade."

    Also see p. 121, n. 62: "This estimate [125 million] is derived from weighted averages of FGM/C prevalence among girls aged 0 to 14 and girls and women aged 15 to 49, using the most recently available DHS, MICS and SHHS data (1997–2012) for the 29 countries where FGM/C is concentrated. The number of girls and women who have been cut was calculated using 2011 demographic figures produced by the UN Population Division ... The number of cut women aged 50 and older is based on FGM/C prevalence in women aged 45 to 49."

  5. ^ a b c UNICEF 2013, p. 50.
  6. ^ a b c d e "FMGC Country Profiles", UNICEF, 22 July 2014 (hereafter UNICEF 2014). For an overview of all the countries listed, see p. 4/4 of each profile; for example, see Benin, "Inter-country statistical overview," p. 4/4.
  7. ^ UNICEF 2013, p. 9; for the bans, Joint Programme on Female Genital Mutilation/Cutting: Accelerating Change, UNFPA–UNICEF, Annual Report 2012, p. 12.
  8. ^ a b UNICEF 2013, p. 8.
  9. ^ UNICEF 2013, p. 44 for traditional circumciser, pp. 45–46 for anaesthetic, p. 46 for blade or razor.

    P. Stanley Yoder, Shanxiao Wang, Elise Johansen, "Estimates of female genital mutilation/cutting in 27 African countries and Yemen", Studies in Family Planning, 44(2), June 2013, pp. 189–204: "The practice of female genital mutilation/cutting (FGM/C) has been documented in many countries in Africa and in several countries in Asia and the Middle East ..." PubMed doi:10.1111/j.1728-4465.2013.00352.x

    For the 29 countries in which it is concentrated (27 countries in Africa, as well as Yemen and Iraqi Kurdistan), UNICEF 2013, pp. 26–27.

  10. ^ a b UNICEF 2013, pp. 47, 50. Also see p. 183.
  11. ^ a b c d e f g h i Jasmine Abdulcadira, et al, "Care of women with female genital mutilation/cutting", Swiss Medical Weekly, 6(14), January 2011 (review). PubMed doi:10.4414/smw.2011.13137
  12. ^ a b WHO 2014; WHO 2008, p. 1: "Female genital mutilation has no known health benefits."
  13. ^ Anika Rahman and Nahid Toubia, Female Genital Mutilation: A Guide to Laws and Policies Worldwide, Zed Books, 2000, pp. 5–6.

    Gerry Mackie, "Ending Footbinding and Infibulation: A Convention Account", American Sociological Review, 61(6), December 1996 (pp. 999–1017, also here), pp. 999–1000.

  14. ^ a b P. Stanley Yoder, Shane Khan, "Numbers of women circumcised in Africa: The Production of a Total", USAID, DHS Working Papers, No. 39, March 2008, pp. 13–14: "Infibulation is practiced largely in countries located in northeastern Africa: Djibouti, Eritrea, Ethiopia, Somalia, and Sudan. Survey data are available for Sudan, Eritrea, Ethiopia and Djibouti. Sudan alone accounts for about 3.5 million of the women. ... [T]he estimate of the total number of women infibulated in [Djibouti, Somalia, Eritrea, northern Sudan, Ethiopia, Guinea, Mali, Burkina Faso, Senegal, Chad, Nigeria, Cameroon and Tanzania, for women 15–49 years old] comes to 8,245,449, or just over eight million women." Also see table on p. 19.

    UNICEF's latest reports do not include Ethiopia as a country where infibulation is most common, and statistics for Sudan were not available. See UNICEF 2013, p. 182, which identifies "sewn closed" as most common in Djibouti, Eritrea, Somalia for 15–49 age group (2000 MICS survey for Sudan not included), and for daughters, Djibouti, Eritrea, Niger, Somalia.

    Also see UNICEF statistical profiles on FGM: Djibouti (December 2013), Eritrea (July 2014), Somalia (December 2013), Sudan (December 2013, type of FMG not listed for Sudan in this profile).

  15. ^ For countries in which it is outlawed or restricted, UNICEF 2013, p. 8.

    For enforcement, UNFPA–UNICEF 2012, p. 48: "Reports from 2012 suggest that successfully prosecuting those who violate laws against FGM/C is difficult. Even in cases where law enforcement officials make arrests, they often fail to collect the necessary evidence."

  16. ^ a b "67/146. Intensifying global efforts for the elimination of female genital mutilation", United Nations General Assembly, adopted 20 December 2012.

    Emma Bonino, "Banning Female Genital Mutilation", The New York Times, 19 December 2012.

  17. ^ Eric K. Silverman, "Anthropology and Circumcision", Annual Review of Anthropology, 33, 2004 (pp. 419–445), pp. 420, 427.
  18. ^ Louisa Kasdon, "A Tradition No Longer", World & I, November–December 2005, p. 67.
  19. ^ Martha Nussbaum, Sex and Social Justice, Oxford University Press, 1999, p. 119; UNICEF 2013, pp. 6–7.
  20. ^ James Karanja, The Missionary Movement in Colonial Kenya: The Foundation of Africa Inland Church, Cuvillier Verlag, 2009, p. 93, n. 631.
  21. ^ "Eliminating Female genital mutilation: An Interagency Statement", OHCHR, UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCR, UNICEF, UNIFEM, WHO, 2008, Annex I: Note on terminology, p. 22.
  22. ^ Rose Oldfield Hayes, "Female Genital Mutilation, Fertility Control, Women's Roles, and the Patrilineage in Modern Sudan: A Functional Analysis", American Ethnologist 2(4), November 1975, pp. 617–633.

    Fran Hosken, The Hosken Report: Genital and Sexual Mutilation of Females, Women's International Network, 1994 [1979].

  23. ^ UNICEF 2013, pp. 6–7.
  24. ^ WHO 2008, p. 4.

    For FGM having become the dominant term, WHO 2008, p. 22: "In 1990, this term was adopted at the third conference of the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, in Addis Ababa, Ethiopia. In 1991, WHO recommended that the United Nations adopt this term. It has subsequently been widely used in United Nations documents and elsewhere and is the term employed by WHO." Also see Nussbaum 1999, p. 119.

  25. ^ WHO 2008, p. 22; for FGM/C, UNICEF 2013, p. 7.

    Rogaia Mustafa Abusharaf, "Introduction: The Custom in Question," in Rogaia Mustafa Abusharaf (ed.), Female Circumcision: Multicultural Perspectives, University of Pennsylvania Press, 2007, p. 6.

  26. ^ a b UNICEF 2013, p. 48.
  27. ^ Fadwa El Guindi, "Had This Been Your Face, Would You Leave It as Is?" in Abusharaf 2007, p. 30.
  28. ^ Chantal Zabus, "The Excised Body in African Texts and Contexts," in Merete Falck Borch (ed.), Bodies and Voices: The Force-field of Representation and Discourse in Colonial and Postcolonial Studies, Rodopi, 2008, p. 47.
  29. ^ Mackie 1996, pp. 1002, 1004.
  30. ^ Chantal Zabus, "Between Rites and Rights: Excision on Trial in African Women's Texts and Human Contexts," in Peter H. Marsden and Geoffrey V. Davis (eds.), Towards a Transcultural Future: Literature and Human Rights in a ' Post'-Colonial World, Rodopi 2004, pp. 112–113.
  31. ^ Ellen Gruenbaum, The Female Circumcision Controversy: An Anthropological Perspective, University of Pennsylvania Press, 2001, pp. 3, 148, 225.
  32. ^ a b Raqiya D. Abdalla, "'My Grandmother Called it the Three Feminine Sorrows': The Struggle of Women Against Female Circumcision in Somalia," in Abusharaf 2007, p. 190.
  33. ^ Haseena Lockhat, Female Genital Mutilation: Treating the Tears, Middlesex University Press, 2004, p. 12.
  34. ^ a b Susan Elmusharaf, Nagla Elhadi, Lars Almroth, "Reliability of self reported form of female genital mutilation and WHO classification: cross sectional study", British Medical Journal, 332(7559), 27 June 2006. PubMed PMC 1502195 doi:10.1136/bmj.38873.649074.55
  35. ^ UNICEF 2013, pp. 42–44 (for cutters), p. 46 (for home and anaesthesia).

    Michael Miller and Francesca Moneti, Changing a harmful social convention: female genital cutting/mutilation, UNICEF 2005, p. 7: "The large majority of girls and women are cut by a traditional practitioner, a category which includes local specialists (cutters or exciseuses), traditional birth attendants and, generally, older members of the community, usually women. This is true for over 80 percent of the girls who undergo the practice in Benin, Burkina Faso, Côte d'Ivoire, Eritrea, Ethiopia, Guinea, Mali, Niger, Tanzania and Yemen. In most countries, medical personnel, including doctors, nurses and certified midwives, are not widely involved in the practice."

    Amal Abd El Hadi, "Female Genital Mutilation in Egypt" in Meredeth Turshen (ed.), African Women's Health, Africa World Press, 2000, p. 148: "In the main dayas (female traditional birth attendants) and barbers (male traditional health workers) perform the circumcision, particularly in rural areas and popular urban areas."

  36. ^ UNICEF 2013, pp. 43–45: "In some countries, such as Egypt, Sudan and Kenya ... a substantial number of health-care providers perform the procedure. This phenomenon is most acute in Egypt, where mothers report that in three out of four cases (77 per cent), FGM/C was performed on their daughters by a trained medical professional. In Egypt, this is most often a doctor, the only country where this holds true. In most countries where medical personnel play a significant role in performing FGM/C, nurses, midwives or other trained health personnel carry out the procedure" (p. 43). See p. 45 for the reference to 1997–2011 surveys.

    Also see "Egypt: Statistical profile on female genital mutilation/cutting", UNICEF, December 2013.

  37. ^ a b Elizabeth Kelly, Paula J. Adams Hillard, "Female genital mutilation", Current Opinion in Obstetrics & Gynecology, 17(5), October 2005, pp. 490–494 (review), p. 491. PubMed
  38. ^ Wairagala Wakabi, "Africa battles to make female genital mutilation history", The Lancet, 369 (9567), 31 March 2007, pp. 1069–1070. PubMed doi:10.1016/S0140-6736(07)60508-X
  39. ^ "Female Genital Mutilation: A Teachers' Guide", World Health Organization, 2005, p. 31: "FGM is carried out using special knives, scissors, razors, or pieces of glass. On rare occasions sharp stones have been reported to be used (e.g. in eastern Sudan), and cauterization (burning) is practised in some parts of Ethiopia. Finger nails have been used to pluck out the clitoris of babies in some areas in the Gambia. The instruments may be re-used without cleaning."
  40. ^ a b UNICEF 2013, p. 46.
  41. ^ UNICEF 2013, p. 3–7 (see p. 126 for the questions).
  42. ^ UNICEF 2013, p. 48: "These categories do not fully match the WHO typology. Cut, no flesh removed describes a practice known as nicking or pricking, which currently is categorized as Type IV. Cut, some flesh removed corresponds to Type I (clitoridectomy) and Type II (excision) combined. And sewn closed corresponds to Type III, infibulation."
  43. ^ "Classification of female genital mutilation", World Health Organization, 2014.

    WHO 2008, p. 4, and Annex 2, p. 24, for Types I–IV; Annex 2, pp. 23–28, for a more detailed discussion.

  44. ^ WHO 2008, p. 25: "[There is a] common tendency to describe Type I as removal of the prepuce, whereas this has not been documented as a traditional form of female genital mutilation. However, in some countries, medicalized female genital mutilation can include removal of the prepuce only (Type Ia) (Thabet and Thabet, 2003), but this form appears to be relatively rare (Satti et al, 2006). Almost all known forms of female genital mutilation that remove tissue from the clitoris also cut all or part of the clitoral glans itself."

    Nahid Toubia, "Female Circumcision as a Public Health Issue", The New England Journal of Medicine, 331(11), 1994, pp. 712–716. PubMed doi:10.1056/NEJM199409153311106

    Carol R. Horowitz, J. Carey Jackson, Mamae Teklemariam, "Female Circumcision" (letters); Toubia's reply. doi:10.1056/NEJM199501193320313

  45. ^ WHO 2014; WHO 2008, p. 4.
  46. ^ WHO 2008, Annex 2, p. 23.
  47. ^ Susan Izett, Nahid Toubia, Female Genital Mutilation: An Overview, World Health Organization, 1998.
  48. ^ WHO 2014: "Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).

    "When it is important to distinguish between the major variations that have been documented, the following subdivisions are proposed: Type IIa, removal of the labia minora only; Type IIb, partial or total removal of the clitoris and the labia minora; Type IIc, partial or total removal of the clitoris, the labia minora and the labia majora." Also see WHO 2008, p. 4.

  49. ^ WHO 2014: "Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).

    "Type IIIa, removal and apposition of the labia minora; Type IIIb, removal and apposition of the labia majora."

  50. ^ Comfort Momoh, "Female genital mutilation" in Comfort Momoh (ed.), Female Genital Mutilation, Radcliffe Publishing, 2005, p. 7.

    Abdulcadira et al 2011: "In the case of infibulation, the urethral orifice and part of the vaginal opening are covered by the scar. In a virgin infibulated woman the small opening left for the menstrual blood and the urine is not wider than 2–3 mm; in sexually active women and after the delivery the vaginal opening is wider but the urethral orifice is often still covered by the scar."

  51. ^ Kelly and Hillard 2005, p. 491 (Kelly and Hillard say the girls are tied for 2–6 weeks); Momoh 2005, pp. 6–7.

    For the egg mixture and progressive loosening of the binding, Edna Adan Ismail, "Female genital mutilation survey in Somaliland", Edna Adan Maternity and Teaching Hospital, 2009, p. 14.

  52. ^ El Guindi 2007, p. 43.
  53. ^ UNICEF 2013, p. 43.
  54. ^ Momoh 2005, p. 7.

    For other descriptions, Ismail 2009, pp. 12–14; Janice Boddy, Wombs and Alien Spirits: Women, Men, and the Zar Cult in Northern Sudan, University of Wisconsin Press, 1989, p. 50.

  55. ^ Kelly and Hillard 2005, p. 491.

    Also see R. J. I. Cooke, B. M. Dickens, "Special commentary on the issue of reinfibulation", International Journal of Gynaecology and Obstetrics, 109(2), May 2010, pp. 97–99. PubMed doi:10.1016/j.ijgo.2010.01.004

    G. I. Serour, "The issue of reinfibulation", International Journal of Gynaecology and Obstetrics, 109(2), May 2010, pp. 93–96. PubMed doi:10.1016/j.ijgo.2010.01.001

    Olukunmi O. Balogun, et al. "Interventions for improving outcomes for pregnant women who have experienced genital cutting", Cochrane Database of Systematic Reviews, 2, 2013. PubMed doi:10.1002/14651858.CD009872.pub2

  56. ^ Kelly and Hillard 2005, p. 491: "In addition to reinfibulation, many women in Sudan undergo a second type of re-suturing called El-Adel, which is performed to recreate the size of the vaginal orifice to be similar to the size created at the time of primary infibulation. Two small cuts are made around the vaginal orifice to expose new tissues to suture, and then sutures are placed to tighten the vaginal orifice and perineum. This procedure, also called re-circumcision, is primarily performed after vaginal delivery, but can also be performed before marriage, after cesarean section, after divorce, and sometimes even in elderly women as a preparation before death."
  57. ^ Hanny Lightfoot-Klein, "The Sexual Experience and Marital Adjustment of Genitally Circumcised and Infibulated Females in The Sudan", The Journal of Sex Research, 26(3), 1989 (pp. 375–392), p. 380. Note: a paragraph break has been added for ease of reading.

    Also see Hanny Lightfoot-Klein, Prisoners of Ritual: An Odyssey Into Female Genital Circumcision in Africa, Routledge, 1989.

  58. ^ WHO 2008, p. 24; UNICEF 2013, p. 7.

    Regarding substances, WHO 2008, p. 24: "A number of practices of this type have been found in several countries, with a large variety of reasons and potential health hazards. Generally, they are performed regularly by adult women on themselves to clean the vagina before or after sexual intercourse or to tighten and strengthen the vagina to enhance their own or their partner's sexual pleasure. The consequences and health risks depend on the substances used, as well as the frequency and technicalities of the procedures."

  59. ^ a b WHO 2008, p. 27.
  60. ^ Mairo Usman Mandara, "Female genital cutting in Nigeria: View of Nigerian Doctors on the Medicalization Debate," in Shell-Duncan and Hernlund, 2000, pp. 98, 100; for fistulae, p. 102.

    Mairo Usman Mandara, "Female genital mutilation in Nigeria", International Journal of Gynecology & Obstetrics, 84(3), pp. 291–298. PubMed doi:10.1016/j.ijgo.2003.06.001

  61. ^ For the countries, Nkiru Nzegwu, "'Osunality' (or African eroticism)" in Sylvia Tamale (ed.), African Sexualities: A Reader, Fahamu/Pambazuka, 2011, p. 262.

    For the rest, Brigitte Bagnol and Esmeralda Mariano, "Politics of Naming Sexual Practices," in Tamale (ed.) 2011, pp. 272–276 (p. 272 for Uganda).

    "Female Genital Mutilation: A Teachers' Guide", World Health Organization, 2005, p. 31: "In some areas (e.g. parts of Congo and mainland Tanzania), FGM entails the pulling of the labia minora and/or clitoris over a period of about 2 to 3 weeks. The procedure is initiated by an old woman designated for this task, who puts sticks of a special type in place to hold the stretched genital parts so that they do not revert back to their original size. The girl is instructed to pull her genitalia every day, to stretch them further, and to put additional sticks in to hold the stretched parts from time to time. This pulling procedure is repeated daily for a period of about two weeks, and usually no more than four sticks are used to hold the stretched parts, as further pulling and stretching would make the genital parts unacceptably long."

  62. ^ "The Gambia Committee on Traditional Practices Affecting the Health of Women and Children", Global Fund for Women; for 76 percent, UNICEF 2013, p. 2.
  63. ^ UNICEF 2005, p. 16.
  64. ^ a b c Kelly and Hillard 2005, pp. 491–492
  65. ^ Amish J. Dave, Aisha Sethi, Aldo Morrone, "Female Genital Mutilation: What Every American Dermatologist Needs to Know", Dermatologic Clinics, 29(1), January 2011, pp. 103–109 (review). PubMed doi:10.1016/j.det.2010.09.002
  66. ^ Stephanie Sinclair, "Inside a Female-Circumcision Ceremony", The New York Times magazine, April 2006, slideshow of images from Indonesia (article).
  67. ^ Emily Banks, et al, "Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries", The Lancet, 367(9525), 3 June 2006, pp. 1835–1841. PubMed doi:10.1016/S0140-6736(06)68805-3

    For the WHO press release about the study, "New study shows female genital mutilation exposes women and babies to significant risk at childbirth", World Health Organization, 2 June 2006.

  68. ^ Rigmor C. Berg, Eva Denisona, "A Tradition in Transition: Factors Perpetuating and Hindering the Continuance of Female Genital Mutilation/Cutting (FGM/C) Summarized in a Systematic Review", Health Care for Women International, 34(10), 2013 (review). PubMed PMC 3783896 doi:10.1080/07399332.2012.721417.
  69. ^ S. Sibiani and A. A. Rouzi, "Sexual function in women with female genital mutilation", Fertility and Sterility, 93(3), February 2010, pp. 722–724. PubMed doi:10.1016/j.fertnstert.2008.10.035
  70. ^ Elizabeth Heger Boyle, Female Genital Cutting: Cultural Conflict in the Global Community, Johns Hopkins University Press, 2002, pp. 34–35.
  71. ^ UNICEF 2013, pp. 26–27, 174.
  72. ^ Gerry Mackie, John LeJeune, "Social Dynamics of Abandonment of Harmful Practices: A New Look at the Theory", Innocenti Working Paper No. 2008-XXX, UNICEF Innocenti Research Centre, 2008, p. 5.
  73. ^ a b T. C. Okeke, et al, "An Overview of Female Genital Mutilation in Nigeria," Annals of Medical Health Sciences Research, 2(1), Jan–June 2012, pp. 70–73. PubMed PMC 3507121 doi:10.4103/2141-9248.96942 Note: this source uses an alternate English name (Fulani) for the Fula in reporting its data; other names in use are Peulh, Poular and Fulbe (see UNICEF 2013, p. 35).

    For population, "Nigeria over 167 million population: Implications and Challenges", National Population Commission, Nigeria.

  74. ^ UNICEF 2013, p. 22.
  75. ^ UNICEF 2013, pp. 3–5 (see the table on p. 5 for how recent the data is); for 125 million, pp. 22, 121, n. 62.

    For more on UNICEF's data collection, "Multiple Indicator Cluster Survey (MICS)", UNICEF, 25 May 2012.

  76. ^ UNICEF 2013, pp. 26–27, 174.

    Prevalence rates in five countries (Benin, Eritrea, Guinea, Nigeria and Yemen) were adjusted in UNICEF 2014.

  77. ^ UNICEF 2013, pp. 28–37.
  78. ^ UNICEF 2013, pp. 27 (for eight percent), 31 (for the regions).

    Berivan A. Yasin, et al, "Female genital mutilation among Iraqi Kurdish women: a cross-sectional study from Erbil city", BMC Public Health, 13, September 2013. PubMed PMC 3844478 doi:10.1186/1471-2458-13-809

  79. ^ For Guinea and Chad, UNICEF 2013, pp. 35–36.

    For Fulani in Nigeria, Okeke, et al 2012, pp. 70–73. It is practised there by the Yoruba, Hausa, Ibo, Ijaw and Kanuri people.

  80. ^ UNICEF 2013, p. 34.
  81. ^ For rural areas, UNICEF 2013, p. 28; for wealth, p. 40; for education, p. 41.
  82. ^ WHO 2008, pp. 29–30.
  83. ^ UNICEF 2013, p. 23: "Although no nationally representative data on FGM/C are available for countries including Colombia, Jordan, Oman, Saudi Arabia and parts of Indonesia and Malaysia, evidence suggests that the procedure is being performed."

    Abdulcadira 2011: "... among immigrant communities in Europe, Canada, United States, Australia and New Zealand." For Scandinavia, Birgitta Essén, Sara Johnsdotter, "Female Genital Mutilation in the West: Traditional Circumcision versus Genital Cosmetic Surgery", Acta Obstetricia Gynecologica Scandinavica, 83(7), July 2004 (pp. 611–613), p. 612. PubMed

  84. ^ Mohammed A. Tag-Eldin, "Prevalence of female genital cutting among Egyptian girls", Bulletin of the World Health Organization, 86(4), April 2008.
  85. ^ "Nigeria: Statistical profile on female genital mutilation/cutting", UNICEF, July 2014 (figures based on 2013 survey).
  86. ^ Yoder and Khan 2008, pp. 13–14.
  87. ^ UNICEF 2014, Djibouti, Eritrea, Somalia. Figures for Type III in Sudan are not available; see Sudan.

    For more on Sudan, Sozan Elmusharaf, "Female genital mutilation : determinants and consequences among girls and women in Sudan", Karolinska Institutet, Solna, December 2013: "This study indicates high prevalence of FGM in Khartoum, with type III being the most prevalent form."

    A. Satti, S. Elmusharaf, et al, "Prevalence and determinants of the practice of genital mutilation of girls in Khartoum, Sudan," Annals of Tropical Paediatrics, 26(4), December 2006, pp. 303–310: "Girls aged 4–9 years (n=255) presenting to a paediatric emergency ward were recruited. ... Twenty per cent of the study group had undergone FGM, 50% of guardians indicated that it would be done later, and 29% stated that the child would not undergo FGM. In 66% of those who had undergone FGM, it was WHO type III.

    "FGM is still practised widely in Khartoum and probably in many parts of northern Sudan and the type undertaken is often the most severe." PubMed

    M. M. Islam, M. M. Uddin, "Female circumcision in Sudan: Future prospects and strategies for eradication", International Family Planning Perspectives, 27, 2001, pp. 71–76: "Pharaonic circumcision is the most prevalent type in Shendi (96%) and Haj-Yousif (69%), followed by Sunna circumcision (3% and 28%, respectively). Women in Juba, however, were most likely to report Sunna circumcision (53%), with 31% reporting the Pharaonic type (Table 1). The data in Table 1 suggest that a slight shift from the Pharaonic type to the Sunna type of circumcision may be occurring in Sudan."

  88. ^ UNICEF 2013, p. 48.
  89. ^ Gerry Mackie, "Female Genital Cutting: The Beginning of the End," in Bettina Shell-Duncan and Ylva Hernlund (eds.), Female "Circumcision" in Africa: Culture Controversy and Change, Lynne Rienner Publishers, 2000 (pp. 253–282), p. 275 (also here).
  90. ^ UNICEF 2005, p. 6.
  91. ^ UNICEF 2013, p. 51.
  92. ^ UNICEF 2013, p. 101.
  93. ^ UNICEF 2013, p. 99.
  94. ^ a b Female Genital Mutilation/Cutting: What Might the Future Hold?, UNICEF, 22 July 2014.

    "Fewer girls threatened by Female Genital Mutilation", UNICEF, 6 February 2013; UNICEF 2013, p. 101.

  95. ^ UNICEF 2013, p. 99. For percentages, p. 101.
  96. ^ UNICEF 2013, p. 85. Also see p. 113.

    For example, UNICEF writes (p. 85), in Mauritania, where the mean age at cutting is one month old, the 15–19 cohort are reporting events from 15–19 years ago, whereas in Egypt, where the mean age is 10 years, the cutting for the same group occurred 5–9 years ago.

  97. ^ UNICEF 2013, p. 23: "The percentage of girls and women of reproductive age (15 to 49) who have experienced any form of FGM/C is the first indicator used to show how widespread the practice is in a particular country ... In the 29 countries where FGM/C is concentrated, almost all girls are cut before the age of 15. Thus, prevalence data among girls and women aged 15 to 49 are considered to reflect their final FGM/C status.

    "A second indicator of national prevalence measures the extent of cutting among daughters aged 0 to 14, as reported by their mothers. Prevalence data for girls reflect their current – not final – FGM/C status, since many of them may not have reached the customary age for cutting at the time of the survey. They are reported as being uncut but are still at risk of undergoing the procedure. Statistics for girls under age 15 therefore need to be interpreted with a high degree of caution ..."

  98. ^ UNICEF 2013, p. 25; also see p. 100.
  99. ^ Salah M. Rasheedemail, Ahmed H. Abd-Ellah, Fouad M. Yousef, "Female genital mutilation in Upper Egypt in the new millennium", International Journal of Gynecology and Obstetrics, 114(1), July 2011, pp. 47–50: "From 2000 to 2009, 3711 of the young participants (89.2%) underwent FGM and 447 (10.8%) did not. The mean age at the time of FGM was 8.2 ± 0.9 years. About three quarters (74.3%) of the procedures were performed at home and the remaining 25.7% at private clinics. ... At the beginning of the new millennium, FGM was most often performed by nurses, general practitioners, or gynecologists, and rarely by barbers or midwifes. As the years went by, the proportion of nurses and gynecologists performing FGM steadily decreased, with a steeper decrease after 2007. In 2008 and 2009, FGM was mostly performed by general practitioners. ... The law made gynecologists, and perhaps also nurses, reluctant to perform FGM, and general practitioners clearly filled the gap." PubMed doi:10.1016/j.ijgo.2011.02.003
  100. ^ Abusharaf 2007, p. 8.
  101. ^ Mackie 2000, p. 256; Mackie 1996, pp. 999–1000: "Footbinding and infibulation correspond as follows. Both customs are nearly universal where practiced; they are persistent and are practiced even by those who oppose them. Both control sexual access to females and ensure female chastity and fidelity. Both are necessary for proper marriage and family honor. Both are believed to be sanctioned by tradition. Both are said to be ethnic markers, and distinct ethnic minorities may lack the practices. Both seem to have a past of contagious diffusion. Both are exaggerated over time and both increase with status. Both are supported and transmitted by women, are performed on girls about six to eight years old, and are generally not initiation rites. Both are believed to promote health and fertility. Both are defined as aesthetically pleasing compared with the natural alternative. Both are said to properly exaggerate the complementarity of the sexes, and both are claimed to make intercourse more pleasurable for the male."
  102. ^ UNICEF 2013, p. 67; also see Mackie and LeJeune 2008, pp. 9–11.
  103. ^ For the baby's head, Gruenbaum 2001, p. 196; for the rest, J. Steven Svoboda, "The Limits of the Law: Comparative Analysis of Legal and Extralegal Methods to Control Child Body Mutilation Practices," in George C. Denniston, et al, Understanding Circumcision, Springer, 2001, p. 325.
  104. ^ Sarah Windle, et al, "Harmful Traditional Practices and Women's Health: Female Genital Mutilation" in John Erihi (ed.), Maternal and Child Health: Global Challenges, Programs, and Policies, Springer 2009, p. 180.
  105. ^ Rahman and Toubia 2000, pp. 5–6.
  106. ^ Gruenbaum 2001, p. 140; also see Boddy 1989, p. 52.
  107. ^ Bagnol and Mariano 2011, pp. 273, 277–280.

    M. Martinelli, J. E. Ollé-Goig, "Female genital mutilation in Djibouti", African Health Sciences, 12(4), December 2012: "The external female genitalia are considered dirty and 'unsightly' and should be flat, rigid and dry ..."

  108. ^ WHO 2008, pp. 27–28; Bagnol and Mariano 2011, pp. 280–281.
  109. ^ Abdalla 2007, p. 187.
  110. ^ Hayes 1975, pp. 620, 624.
  111. ^ El Dareer 1983, p. 140.
  112. ^ UNICEF 2013, pp. 54, 90.
  113. ^ El Guindi 2007, pp. 36–37.
  114. ^ Fuambai Ahmadu, "Rites and Wrongs: An Insider/Outsider Reflects on Power and Excision," in Shell-Duncan and Hernlund 2000, p. 284–285.
  115. ^ Silverman 2004, p. 429.
  116. ^ a b UNICEF 2013, p. 15.
  117. ^ Boyle 2002, p. 37.

    For Tanzania, Boyle cites R. Mabala, S. R. Kamazima, The Girl Child in Tanzania: Today's Girl, Tomorrow's Woman, A Research Report, UNICEF, Dar es Salaam, 1995.

  118. ^ Gerry Mackie, "Female Genital Cutting: A Harmless Procedure?", Medical Anthropology Quarterly, 17(2), 2003 (pp. 135–158), pp. 147–148.
  119. ^ UNFPA–UNICEF 2012, p. 18.

    Gerry Mackie, John LeJeune, "Social Dynamics of Abandonment of Harmful Practices: A New Look at the Theory", Innocenti Working Paper No. 2009-06, UNICEF Innocenti Research Centre, May 2009.

    Kwame Anthony Appiah, "The Art of Social Change", The New York Times Magazine, 22 October 2010, p. 2.

  120. ^ Mackie 2000, pp. 253–261.

    Louisa Kasdon, "A Tradition No Longer", World & I, November–December 2005, pp. 66–73.

    Nafissatou J. Diop, Amadou Moreau, Hélène Benga, "Evaluation of the Long-term Impact of the TOSTAN Programme on the Abandonment of FGM/C and Early Marriage: Results from a qualitative study in Senega", UNICEF, January 2008.

    Jean Faraca, "Confronting Female Genital Cutting", Wisconsin Public Radio, interview with Molly Melching and Gerry Mackie, 3 November 2011, from 2:43 mins.

    UNICEF-UNFPA 2012, pp. 21–22.

  121. ^ For Malicounda Bambara, see Mackie 2000, p. 256ff (also here).

    For over 7,000 communities, "Our Success", Tostan, accessed 25 October 2014.

  122. ^ UNICEF 2013, pp. 69–70; table on p. 71.
  123. ^ Mackie and LeJeune 2008, p. 8: "Data on the role of religion are difficult to interpret because in many cases, religion, tradition and chastity are not differentiated."
  124. ^ a b UNFPA-UNICEF Joint Programme on Female Genital Mutilation/Cutting: Accelerating Change. Summary Report of Phase I, 2008–2013 (hereafter 2013 UNFPA-UNICEF Joint Programme evaluation report), p. 26.
  125. ^ Mackie 1996, p. 1004.
  126. ^ Mackie 1996, pp. 1004–1005: "The Koran is silent on FGM, but several hadith (sayings attributed to Mohammed) recommend attenuating the practice for the woman's sake, praise it as noble but not commanded, or advise that female converts refrain from mutilation because even if pleasing to the husband it is painful to the wife."

    Nussbaum 1999, p. 125: "The one reference to the operation in the hadith classifies it as a makrama, or nonessential practice."

  127. ^ Mackie, p. 1008: "FGM is pre-Islamic but was exaggerated by its intersection with the Islamic modesty code of family honor, female purity, virginity, chastity, fidelity, and seclusion."

    Also see Ibrahim Lethome Asmani, Maryam Sheikh Abdi, "Delinking Female Genital Mutilation/Cutting from Islam", USAID/UNFPA, 2008.

  128. ^ "Fresh progress toward the elimination of female genital mutilation and cutting in Egypt", UNICEF, 2 July 2007; UNICEF 2013, p. 70.

    Maggie Michael, "Egypt Officials Ban Female Circumcision", The Associated Press, 29 June 2007, p. 2: "[Egypt's] supreme religious authorities stressed that Islam is against female circumcision. It's prohibited, prohibited, prohibited," Grand Mufti Ali Gomaa said on the privately owned al-Mahwar network."

  129. ^ For animist groups, UNICEF 2013, p. 175; for Christians, p. 73.
  130. ^ UNICEF 2013, front page: "Niger. 55% of Christian girls and women have undergone FGM/C, compared to 2% of Muslim girls and women," and p. 73.
  131. ^ Samuel Waje Kunhiyop, African Christian Ethics, Zondervan, 2008, p. 297: "Nowhere in all of Scripture or in any of recorded church history is there even a hint that women were to be circumcised."

    For missionaries, Jocelyn Murray, "The Church Missionary Society and the 'Female Circumcision' Issue in Kenya 1929–1932", Journal of Religion in Africa, 8(2), 1976, pp. 92–104.

  132. ^ Shaye J. D. Cohen, Why Aren't Jewish Women Circumcised? Gender and Covenant In Judaism, University of California Press, 2005, p. 59; Adele Berlin (ed.), "Circumcision," The Oxford Dictionary of the Jewish Religion, Oxford University Press, 2011, p. 173.
  133. ^ Mary Knight, "Curing Cut or Ritual Mutilation?: Some Remarks on the Practice of Female and Male Circumcision in Graeco-Roman Egypt", Isis, 92(2), June 2001 (pp. 317–338), p. 330. Knight references Egyptian Museum sarcophagus cat. no. 28085.

    Also see Adriaan de Buck and Alan H. Gardiner, The Egyptian Coffin Texts, Chicago University Press, 1961, Vol. 7, pp. 448–450.

  134. ^ Mackie 1996, p. 1003; Abusharaf 2007, p. 2.
  135. ^ Mackie 2000, pp. 264, 267; UNICEF 2013, p. 30; Shell-Duncan and Hernlund 2000, p. 13.

    Mackie 1996, p. 1003: FGM's distribution suggests an origin "on the western coast of the Red Sea, where infibulation is most intense, diminishing to clitoridectomy in westward and southward radiation."

    Also see C. G. Seligman, "Aspects of the Hamitic problems in the Anglo-Egyptian Sudan",The Journal of the Royal Anthropological Institute of Great Britain and Ireland, 1913, 40(3), (pp. 593–705), pp. 612, 639–640; Esther K. Hicks, Infibulation: Female Mutilation in Islamic Northeastern Africa, Transaction Publishers, 1996, p. 19ff.

  136. ^ Knight 2001, p. 330. For the hieroglyphs, Paul F. O'Rourke, "The 'm't-Woman", Zeitschrift für Ägyptische Sprache und Altertumskunde, 134(2), February 2007.

    Knight adds that Egyptologists are uncomfortable with the translation to uncircumcised, because there is no information about what constituted the circumcised state.

  137. ^ O'Rourke 2007, p. 172.
  138. ^ Knight 2001, pp. 329–330; F. G. Kenyon, Greek Papyri in the British Museum, British museum, 1893, pp. 31–32 (also here).
  139. ^ Knight 2001, p. 331, citing G. Elliot Smith, A Contribution to the Study of Mummification in Egypt, 1906, p. 30.

    Knight also quotes Marc Armand Ruffer, Studies in the Paleopathology of Egypt, University of Chicago Press, 1921, p. 171: "[T]he bodies are in such a state that it would often be difficult to state with certainty whether such an operation had been done." Knight adds: "In light of the fact that only rarely have scientific researchers autopsying mummies specifically looked for the presence or absence of FGM, conclusive remarks about the prevalence of the practice must await a detailed study of a large cohort of female mummies."

  140. ^ a b Knight 2001, p. 318.

    Strabo, Geography of Strabo, Book VII, chapter 2, 17.2.5, wrote: "One of the customs most zealously observed among the Aegyptians is this, that they rear every child that is born, and circumcise [peritemnein] the males, and excise [ektemnein] the females, as is also customary among the Jews, who are also Aegyptians in origin, as I have already stated in my account of them."

    Strabo, Geography of Strabo, Book XVI, chapter 4, 16.4.9: "And then to the Harbour of Antiphilus, and, above this, to the Creophagi [meat-eaters], of whom the males have their sexual glands mutilated [kolobos] and the women are excised [ektemnein] in the Jewish fashion." A different translation here reads: "Then follows the harbour of Antiphilus, and above this a tribe, the Creophagi, deprived of the prepuce, and the women are excised after the Jewish custom."

    Cohen 2005, p. 59ff, argues that Strabo conflated the Jews with the Egyptians. Jacob Neusner, Approaches to Ancient Judaism, Volume 4, Scholars Press, 1993, p. 148: "the Greek verb περιτέμνειν [peritemnein] 'to cut around/off,' denoted not only circumcision but could be used of any mutilation of body parts, such as the severing of a nose or ears; in Herodotus it is associated with various barbarian practices."

    Knight 2001, p. 326, writes that there is one extant reference from antiquity, from Xanthus of Lydia in the fifth century BCE, that may allude to FGM outside Egypt. Xanthus wrote, in a history of Lydia: "The Lydians arrived at such a state of delicacy that they were even the first to 'castrate' their women." Knight argues that the "castration," which is not described, may have kept women youthful, in the sense of allowing the Lydian king to have intercourse with them without pregnancy. Knight concludes that it may have been a reference to sterilization, not FGM.

  141. ^ Knight 2001, p. 333.
  142. ^ Knight 2001, p. 326 (Knight writes that the attribution to Galen is suspect).
  143. ^ a b Knight 2001, pp. 327–328. A paragraph break has been added for ease of reading.
  144. ^ Mackie 1996, p. 1003: "Whatever the earliest origins of FGM, there is certainly an association between infibulation and slavery."
  145. ^ Mackie 1996, p. 1003, citing João dos Santos, Ethiopia Oriental, 1609, in G. S. P. Freeman-Grenville (ed.), The East-African Coast: Select Documents from the First to the Earlier Nineteenth Century, Clarendon Press, 1962.
  146. ^ Mackie 1996, p. 1003. Footnote 4: The Swedish ethnographer, Carl Gösta Widstrand ("Female Infibulation," Studia Ethnographica Upsaliensia, XX, 1960, pp. 95–124) argued that slave traders had simply paid a higher price for women who were already infibulated.
  147. ^ Mackie 1996, p. 1009.
  148. ^ a b J. F. C. "Isaac Baker Brown, F.R.C.S.," Medical Times and Gazette, 8 February 1873, p. 155; Peter Lewis Allen, The Wages of Sin: Sex and Disease, Past and Present, University of Chicago Press, 2000, p. 106.
  149. ^ Sarah W. Rodriguez, "Rethinking the history of female circumcision and clitoridectomy: American medicine and female sexuality in the late nineteenth century", Journal of the History of Medicine and Allied Sciences. 63(3), July 2008, pp. 323–347. PubMed doi:10.1093/jhmas/jrm044
  150. ^ Robert Thomas, The Modern Practice of Physick, Longman, Hurst, Rees, Orme, and Brown, 1813, pp. 585–586.

    Edward Shorter, From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era, Simon and Schuster, 2008, p. 82.

  151. ^ Uriel Elchalal, et al, "Ritualistic Female Genital Mutilation: Current Status and Future Outlook", Obstetrical & Gynecological Survey, 52(10), October 1997, pp. 643–651. PubMed
  152. ^ John Black, "Female genital mutilation: a contemporary issue, and a Victorian obsession", Journal of the Royal Society of Medicine, 90, July 1997 (pp. 402–405), p. 403, 404–405. PubMed PMC 1296388

    Lewis 2000, p. 106; Elizabeth Sheehan, "Victorian Clitoridectomy: Isaac Baker Brown and His Harmless Operative Procedure", Medical Anthropology Newsletter, 12(4), August 1981. PubMed

  153. ^ Deborah Kuhn McGregor, From Midwives to Medicine: The Birth of American Gynecology, Rutgers University Press, 1998, p. 146.
  154. ^ G. J. Barker-Benfield, The Horrors of the Half-Known Life: Male Attitudes Toward Women and Sexuality in Nineteenth-Century America, Routledge, 1999, p. 113.
  155. ^ L. P. Cutner, "Female genital mutilation", Obstetrical & Gynecological Survey, 40(7), July 1985, pp. 437–443. PubMed Cited in Nawal M. Nour, "Female Genital Cutting: A Persisting Practice", Reviews in Obstetrics and Gynecology, 1(3), Summer 2008, pp. 135–139. PubMed PMC 2582648
  156. ^ Kenneth Mufuka, "Scottish Missionaries and the Circumcision Controversy in Kenya, 1900–1960", International Review of Scottish Studies, 28, 2003, p. 55.
  157. ^ Lynn M. Thomas,"'Ngaitana (I will circumcise myself)': Lessons from Colonial Campaigns to Ban Excision in Meru, Kenya" in Shell-Duncan and Hernlund, 2000, p. 132.

    For irua, Jomo Kenyatta, Facing Mount Kenya, Vintage, 1962 [1938], p. 129; for irugu being outcasts, Kenyatta, p. 127, and Zabus 2008, pp. 48–49.

  158. ^ Kenyatta 1962 [1938], pp. 127–130.
  159. ^ Klaus Fiedler, Christianity and African Culture, Brill, 1996, p. 75.
  160. ^ Janice Boddy, Civilizing Women: British Crusades in Colonial Sudan, Princeton University Press, 2007, pp. 241–245.

    Also see Ronald Hyam, Empire and Sexuality: The British Experience, Manchester University Press, 1990; Jocelyn Murray, "The Church Missionary Society and the 'Female Circumcision' Issue in Kenya 1929-1932", Journal of Religion in Africa, 8(2), 1976, pp. 92–104.

  161. ^ Thomas 2000, p. 132; for the "sexual mutilation of women," Karanja 2009, p. 93, n. 631.

    Also see Robert Strayer, Jocelyn Murray, "The CMS and Female Circumcision," in Robert Strayer (ed.), The Making of Missionary Communities in East Africa, SUNY Press, 1978, p. 139ff.

  162. ^ Boddy 2007, p. 241.
  163. ^ Thomas 2000, pp. 129–131 (p. 131 for the girls as "central actors"); Lynn Thomas, Politics of the Womb: Women, Reproduction, and the State in Kenya, University of California Press, 2003, pp. 89–91.

    Also see Lynn M. Thomas, "'Ngaitana (I will circumcise myself)': The Gender and Generational Politics of the 1956 Ban on Clitoridectomy in Meru, Kenya", Gender and History, 8(3), November 1996, pp. 338–363.

    Kenya criminalized FGM in 2001 for the under-18s and banned it from state-run facilities, then banned it completely with the Prohibition of FGM Act 2011. See UNICEF-UNFPA 2012, pp. 12, 14; Sarah Boseley, "FGM: Kenya acts against unkindest cut", The Guardian, 8 September 2011.

  164. ^ UNICEF 2013, p. 10, calls the Egyptian Doctors' Society opposition the "first known campaign" against FGM; for independence, Boddy 2007, p. 147.
  165. ^ Boddy 2007, pp. 202, 299.

    FGM is still practised in Sudan, where 88 percent of women and girls have been cut; some states banned it in 2008–2009, but as of 2013 there was no national legislation (UNICEF 2013, pp. 2, 9).

  166. ^ Boyle 2002, pp. 92, 103.
  167. ^ Boyle 2002, p. 41.
  168. ^ Birgitte Bagnol, Esmeralda Mariano, "Politics of naming sexual practices," in Sylvia Tamale (ed.), African Sexualities: A Reader, Pambazuka Press, 2011, p. 281.
  169. ^ Gruenbaum 2001, p. 22.

    Homa Khaleeli, "Nawal El Saadawi: Egypt's radical feminist", The Guardian, 15 April 2010.

    Jenna Krajeski, "The Books of Nawal El Saadawi", The New Yorker, 7 March 2011.

    Jenna Krajeski, "Rebellion", The New Yorker, 14 March 2011.

  170. ^ Nawal El Saadawi, The Hidden Face of Eve, Zed Books, 2007 [1980], p. 14; Krajeski (The New Yorker), 7 March 2011.
  171. ^ Oldfield Hayes 1975, p. 618; Gruenbaum 2001, p. 21.
  172. ^ Yoder and Khan (USAID) 2008, p. 2.

    Fran Hosken, The Hosken Report: Genital and Sexual Mutilation of Females, Women's International Network, 1994 [1979].

    Claire C. Robertson, "Getting beyond the Ew! Factor: Rethinking U.S. Approaches to African Female Genital Cutting," in Stanlie M. James and Claire C. Robertson (eds.), Genital Cutting and Transnational Sisterhood, University of Illinois Press, 2002 (pp. 54–86), p. 60: "The Hosken Report is the single most influential document responsible for raising consciousness of FGC."

    Also see Joseph P. Khan, "Fran P. Hosken, 86; activist for women's issues globally", The Boston Globe, 12 February 2006.

  173. ^ Mackie 2003, p. 139.
  174. ^ Hosken 1994 [1979], p. 5.
  175. ^ Boyle 2002, p. 47; Bagnol and Mariano 2011, p. 281.
  176. ^ Rahman and Toubia 2000, p. 10–11; for Vienna, also see UNICEF 2013 p. 8.
  177. ^ Emma Bonino, "A brutal custom: Join forces to banish the mutilation of women", The New York Times, 15 September 2004.

    Maputo Protocol, pp. 7–8.

  178. ^ For example, UNICEF 2013 lists Mauritania as having passed legislation against FGM, but (as of that year) it is banned only from being conducted in government facilities or by medical personnel. See UNICEF 2013, p. 8.

    For the 22 countries, UNICEF 2013, pp. 8–9 (an asterisk indicates a ban according to the UNICEF–UNFPA 2012 annual report, p. 12, although that list may not be exhaustive):

    Benin (2003), Burkina Faso (1996*), Central African Republic (1966, amended 1996), Chad (2003), Côte d'Ivoire (1998), Djibouti (1995, amended 2009*), Egypt (2008*), Eritrea (2007*), Ethiopia (2004*), Ghana (1965, amended 2007), Guinea (1965, amended 2000*), Guinea-Bissau (2011*), Kenya (2001, amended 2011*), Mauritania (2005), Niger (2003), Nigeria, some states (1999–2006), Senegal (1999*), Somalia (2012*), Sudan, some states (2008–2009), Tanzania (1998), Togo (1998) and Uganda (2010*).

    South Africa and Zambia have outlawed it, but are not among the countries in which it is concentrated. Outside Africa it is concentrated in Yemen (2001) and Iraqi Kurdistan (2011), both of which have passed legislation against it.

  179. ^ For CNN, Salam 1999, p. 322.

    For the religious ruling, UNICEF 2013, p. 70. "Fresh progress toward the elimination of female genital mutilation and cutting in Egypt", UNICEF, 2 July 2007.

    For the ministerial ban and penal code, "National Legislation, Decrees and Statements Banning FGM/C", UNFPA Egypt.

  180. ^ Patrick Kingsley, "Egyptian doctor to stand trial for female genital mutilation in landmark case", The Guardian, 21 May 2014.

    Sara Abdel Rahim, "From Midwives to Doctors: Searching for “Safer” Circumcisions in Egypt?", The Tahrir Institute for Middle East Policy, 9 September 2014.

  181. ^ "48/104. Declaration on the Elimination of Violence against Women", United Nations General Assembly, 20 December 1993.
  182. ^ Charlotte Feldman-Jacobs, "Commemorating International Day of Zero Tolerance to Female Genital Mutilation", Population Reference Bureau, February 2009.
  183. ^ "UNFPA–UNICEF Joint Programme on Female Genital Mutilation/Cutting: Accelerating Change", Volume 1, 2008–2012, September 2013, p. viii.
  184. ^ 2013 UNFPA-UNICEF Joint Programme evaluation report, p. 38.
  185. ^ "Joint Programme on the Abandonment of Female Genital Mutilation/Cutting. Funding Proposal for a Phase II", UNFPA–UNICEF.

    "Joint Programme on the Abandonment of Female Genital Mutilation/Cutting. Management Response and Key Actions", UNFPA–UNICEF.

  186. ^ 2013 UNFPA-UNICEF Joint Programme evaluation report, pp. 4, 16–17; for alternative rites of passage and the Saleema initiative, pp. 22–23.
  187. ^ UNFPA–UNICEF 2012, p. 48.
  188. ^ UNFPA–UNICEF 2012, pp. 12–13.
  189. ^ UNICEF 2005, p. 4: "Beyond economic factors, migratory patterns have frequently reflected links established in the colonial past. For instance, citizens from Benin, Chad, Guinea, Mali, Niger and Senegal have often chosen France as their destination, while many Kenyan, Nigerian and Ugandan citizens have migrated to the United Kingdom.

    "In the 1970s, war, civil unrest and drought in a number of African states, including Eritrea, Ethiopia and Somalia, resulted in an influx of refugees to Western Europe, where some countries, such as Norway and Sweden, had been relatively unaffected by migration up to that point. Beyond Western Europe, Canada and the USA in North America, and Australia and New Zealand in Australasia also host women and children who have been subjected to FGM/C, and are home to others who are at risk of undergoing this procedure."

  190. ^ Birgitta Essén, Sara Johnsdotter, "Female Genital Mutilation in the West: Traditional Circumcision versus Genital Cosmetic Surgery", Acta Obstetricia Gynecologica Scandinavica, 83(7), July 2004 (pp. 611–613), p. 611. PubMed
  191. ^ Boyle 2002 p. 97.
  192. ^ "Review of Australia's Female Genital Mutilation Legal Framework", Attorney General's Department, Government of Australia; "Section 204A – Female genital mutilation – Crimes Act 1961", New Zealand Parliamentary Counsel Office.

    "Eliminating female genital mutilation", European Commission; "18 U.S. Code § 116 - Female genital mutilation", Legal Information Institute, Cornell University Law School; Section 268, Criminal Code of Canada.

  193. ^ Douglas Martin, "Efua Dorkenoo Dies at 65; Key Foe of Genital Cutting in Africa, Middle East", The New York Times, 27 October 2014.

    Efua Dorkenoo, Cutting the Rose: Female Genital Mutilation, the Practice and its Prevention, Minority Rights Group, 1994.

  194. ^ Clyde H. Farnsworth, "Canada Gives Somali Mother Refugee Status", The New York Times, 21 July 1994.
  195. ^ Section 268, Criminal Code of Canada; UNICEF 2013, p. 8.

    Also see Audrey Macklin, "The Double-Edged Sword: Using the Criminal Law Against Female Genital Mutilation," in Abusharaf 2007, p. 211ff.

  196. ^ Mobina S. B. Jaffer, "Criminal Code, Bill to Amend – Second Reading, Debates of the Senate (Hansard), 1st Session, 41st Parliament, 148(79), 15 May 2012: "Another example of legislation that was honourable in principle but lacked the resources to be effective was the one that criminalized female genital mutilation. In 1995, in the Second Session of the Thirty-fifth Parliament, Bill C-27 was passed making female genital mutilation a criminal act; therefore, in Canada this practice is considered a criminal offence. Those who perform this procedure can be charged under the Criminal Code of Canada. Unfortunately, over the past 17 years not one conviction has been made, even though there is evidence indicating that this practice still takes place in Canada."
  197. ^ Megan Rowling "France reduces genital cutting with prevention, prosecutions – lawyer", Thomson Reuters Foundation, 27 September 2012.
  198. ^ Renée Kool1 and Sohail Wahedi, "Criminal Enforcement in the Area of Female Genital Mutilation in France, England and the Netherlands: A Comparative Law Perspective", International Law Research, 3(1), 2014, p. 4. doi:10.5539/ilr.v3n1p1
  199. ^ Rowling 2012.

    John Lichfield, "The French way: a better approach to fighting FGM?", The Independent, 15 December 2013.

  200. ^ Colette Gallard, "Female genital mutilation in France", British Medical Journal, 310, 17 June 1995, p. 1592. PubMed PMC 2549952

    That one girl was three months old, Rowling 2012.

  201. ^ For 1982, Gallard (BMJ) 1995, p. 1593; for 1993, Farnsworth (New York Times) 1994.
  202. ^ David Gollaher, Circumcision: A History of the World's Most Controversial Surgery, Basic Books, 2000, p. 189.
  203. ^ Alison Macfarlane and Efua Dorkenoo, "Female Genital Mutilation in England and Wales", City University of London and Equality Now, 21 July 2014, p. 3.

    Also see "Female Genital Mutilation: Report of a Research Methodological Workshop on Estimating the Prevalence of FGM in England and Wales", Equality Now, 22–23 March 2012.

    For an earlier report, Efua Dorkenoo, Linda Morison, Alison Macfarlane, "A Statistical Study to Estimate the Prevalence of Female Genital Mutilation in England and Wales", FORWARD, October 2007.

    For an early article about FGM in the UK, J. A. Black, G. D. Debelle, "Female genital mutilation in Britain", British Medical Journal, 310, 17 June 1995. PubMed PMC 2549951 doi:10.1136/bmj.310.6994.1590

  204. ^ Female Genital Mutilation Act 2003: "A person is guilty of an offence if he excises, infibulates or otherwise mutilates the whole or any part of a girl's labia majora, labia minora or clitoris," unless "necessary for her physical or mental health."

    Although the legislation refers to girls, it applies to women too. See "Female Genital Mutilation Act 2003", legislation.gov.uk, and "Female Genital Mutilation Act 2003" (legal guidance), Crown Prosecution Service: "The Act refers to 'girls', though it also applies to women."

    "Prohibition of Female Circumcision Act 1985", "Female Genital Mutilation Act 2003", "Prohibition of Female Genital Mutilation (Scotland) Act 2005", legislation.gov.uk.

  205. ^ "Concluding observations on the seventh periodic report of the United Kingdom of Great Britain and Northern Ireland", United Nations Convention on the Elimination of All Forms of Discrimination against Women, 26 July 2013, p. 6, paras 36, 37.
  206. ^ "FGM: UK's first female genital mutilation prosecutions announced", BBC News, 21 March 2014.
  207. ^ Wanda K. Jones, et al, "Female Genital Mutilation/Female Circumcision: Who Is at Risk in the U.S.?", Public Health Reports, 112, September/October 1997 (pp. 368–377), p. 372.
  208. ^ For Nigerian woman, Patricia Dysart Rudloff, "In Re: Oluloro: Risk of female genital mutilation as 'extreme hardship' in immigration proceedings", 26 Saint Mary's Law Journal, 877, 1995.

    For Fauziya Kasinga, Nussbaum 1999, pp. 118–119.

    Celia W. Dugger, "June 9–15; Asylum From Mutilation",The New York Times, 16 June 1996.

    "In re Fauziya KASINGA, file A73 476 695", U.S. Department of Justice, Executive Office for Immigration Review, decided 13 June 1996.

  209. ^ For Illegal Immigration Reform and Immigrant Responsibility Act, Abusharaf 2007, p. 22; "18 U.S. Code § 116 – Female genital mutilation", Legal Information Institute, Cornell University Law School.

    Susan Deller Ross, Women's Human Rights: The International and Comparative Law Casebook, Vantage Press, 2008, p. 509–511; "Legislation on Female Genital Mutilation in the United States", Center for Reproductive Rights, November 2004, p. 3.

    For Transport for Female Genital Mutilation Act, "One Hundred Twelfth Congress of the United States of America", 3 January 2012, Sec 1088, p. 339.

  210. ^ Current policy: "Female Genital Mutilation", Pediatrics, 102(1), 1 July 1998, pp. 153–156. PubMed

    Withdrawn policy: "Ritual Genital Cutting of Female Minors", Pediatrics, 25(5), 1 May 2010, pp. 1088–1093. PubMed doi:10.1542/peds.2010-0187

    Pam Belluck, "Group Backs Ritual 'Nick' as Female Circumcision Option", The New York Times, 6 May 2010.

    Susan Bewley, Sarah Creighton and Comfort Momoh, "Female genital mutilation: Paediatricians should resist its medicalisation", British Medical Journal, 340(7760), 19 June 2010, pp. 1317–1318.

  211. ^ "Man gets 10-year sentence for circumcision of 2-year-old daughter", Associated Press, 1 November 2006.

    In 2014 President Barack Obama spoke about FGM for the first time, calling it "a tradition that's barbaric and should be eliminated." See Nedra Pickler, "Obama To Rename Africa Young Leaders Program For Nelson Mandela", Huffington Post, 28 July 2014.

  212. ^ Silverman 2004, p. 431.
  213. ^ Silverman 2004, pp. 420 (for the quote), 427.
  214. ^ Vicky Kirby, "Out of Africa: 'Our Bodies Ourselves?'" in Obiama Nnaemeka (ed.), Female Circumcision and the Politics of Knowledge: African Women in Imperialist Discourses, Praeger, 2005, p. 83.

    For the issue of naming, Obioma Nnaemeka, "African Women, Colonial Discourses, and Imperialist Interventions: Female Circumcision as Impetus," in Nnaemeka 2005, p. 33.

  215. ^ Obioma Nnaemeka, "African Women, Colonial Discourses, and Imperialist Interventions: Female Circumcision as Impetus," in Nnaemeka (ed.) 2005, p. 34; p. 35 for "If one is circumcised, it is one too many."
  216. ^ a b Sylvia Tamale, "Researching and theorising sexualities," in Sylvia Tamale (ed.), African Sexualities: A Reader, Fahamu/Pambazuka, 2011, pp. 19–20.
  217. ^ Nnaemeka 2005, p. 33.
  218. ^ Christine J. Walley, "Searching for 'Voices': Feminism, Anthropology, and the Global Over Female Genital Operations" in James and Robertson (eds.) 2002, pp. 18, 34, 43.

    For the statement, Bagnol and Mariano 2011, p. 281.

  219. ^ "Stephanie Welsh", 1996 Pulitzer Prize winners
  220. ^ Chima Korieh, "'Other' Bodies: Western Feminism, Race and Representation in Female Circumcision Discourse," in Nnaemeka (ed.) 2005, pp. 121–122.

    For the photographs, "Stephanie Welsh", 1996 Pulitzer Prize winners.

    For other examples, Nnaemeka 2005, pp. 30–33.

  221. ^ Richard Shweder, "When Cultures Collide: Which Rights? Whose Tradition of Values? A Critique of the Global Anti-FGM Campaign," in Christopher L. Eisgruber and András Sajó (eds.), Global Justice And the Bulwarks of Localism, Martinus Nijhoff, 2005 (pp. 181–199), p. 187.

    Richard Shweder, "'What About Female Genital Mutilation?' And Why Understanding Culture Matters in the First Place," Daedalus, 129(4), Fall 2000 (pp. 209–232), pp. 218–219.

    Carla Obermeyer, "Female Genital Surgeries: The Known, the Unknown and the Unknowable", Medical Anthropology Quarterly, 31(1), 1999 (pp. 79–106), pp. 92–93. PubMed

    Carla Obermeyer, "The Health Consequences of Female Circumcision: Science, Advocacy, and Standards of Evidence", Medical Anthropology Quarterly, 17(3), September 2002. PubMed

    Carla Obermeyer, "The Consequences of Female Circumcision for Health and Sexuality: An Update on the Evidence", Medical Anthropology Quarterly, 7(5), September–October 2005. PubMed

  222. ^ Mackie 2003, p. 137.
  223. ^ Sweder 2005, pp. 187–189; Linda Morison, et al, "The long-term reproductive health consequences of female genital cutting in rural Gambia: a community-based survey", Tropical Medicine & International Health, 6(8), August 2001, pp. 643–653. PubMed
  224. ^ Nnaemeka 2005, pp. 38–39.
  225. ^ Sara Johnsdotter and Birgitta Essén, "Genitals and ethnicity: the politics of genital modifications", Reproductive Health Matters, 18(35), 2010 (pp. 29–37), p. 32. PubMed doi:10.1016/S0968-8080(10)35495-4

    Samar A. Farage, "Female Genital Alteration: A Sociological Perspective," in Miranda A. Farage and Howard I. Maibach (eds.), The Vulva: Anatomy, Physiology, and Pathology, CRC Press, 2006, p. 267.

    Marge Berer, "It's female genital mutilation and should be prosecuted", British Medical Journal, 334(7608), 30 June 2007, p. 1335. PubMed PMC 1906631 doi:10.1136/bmj.39252.646042.3A

  226. ^ Ronán M. Conroy, "Female genital mutilation: whose problem, whose solution?", British Medical Journal, 333(7559), 15 July 2006. PubMed PMC 1502236
  227. ^ El Guindi 2007, pp. 33–34.
  228. ^ Lora Wildenthal, The Language of Human Rights in West Germany, University of Pennsylvania Press, 2012, p. 148.
  229. ^ Obermeyer 1999, p. 94.
  230. ^ WHO 2008, p. 28.
  231. ^ Johnsdotter and Essén 2010, p. 32.
  232. ^ Johnsdotter and Essén 2010, p. 33; Essén and Johnsdotter 2004, p. 613.
  233. ^ Nussbaum 1999, pp. 123–124.

    Also see Yael Tamir, "Hands Off Clitoridectomy", Boston Review, Summer 1996.

    Martha Nussbaum, "Double Moral Standards?", Boston Review, October/November 1996.

  234. ^ Nancy Ehrenreich, Mark Barr, "Intersex Surgery, Female Genital Cutting, and the Selective Condemnation of 'Cultural Practices'", Harvard Civil Rights-Civil Liberties Law Review, 40(1), 2005 (pp. 71–140), pp. 74–75.

    Also see Cheryl Chase, "'Cultural Practice' or 'Reconstructive Surgery'? US Genital Cutting, the Intersex Movement, and Medical Double Standards," in James and Robertson (eds.) 2002, pp. 126–151.

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