Welcome back, everyone! We’re discussing an enraging and terrifying topic this week - female genital mutilation/cutting/circumcision (FGM/C).
FGM/C is the partial or total removal of the female external genitalia or other injuries to the female genital organs for non-medical reasons. According to the World Health Organization (WHO), FGM/C is a common cultural practice in some parts of Africa (the Western, Eastern, and North-Eastern regions) and some countries in the Middle East and Asia - where an estimated 200 million girls and women alive today have been subjected to it.
I must admit, this has been the most difficult thing I’ve written about so far. I have written and rewritten this post about 5 times and my rage grew with every revised version of it. My initial approach was a conservative one because of how sensitive cultural and traditional practices are. I was aiming for a more non-judgmental approach but I realised that in doing so I felt so passive like I was just relaying information and not engaging with it, all because I was scared of offending people. The more research I did, the more I realised that tiptoeing around such topics is what nurtures some of these cultural practices that actually violate human rights. I also had to remind myself that my job is to educate and have difficult conversations. I have no personal experience of FGM/C nor do I know anyone who has undergone it so I may not fully comprehend the reasons for this practice, but as someone born with a vulva I feel it would be harmful and a form of betrayal to be hush about this.
Let’s get into it, shall we?
So, there are four major types of FGM/C:
Type 1 “clitoridectomy” is the partial or total removal of the clitoris and, in very rare cases, only the clitoral hood (skin fold surrounding the clitoris)
Type 2 “excision” is the partial or total removal of the clitoris, labia minora, with or without removal of the labia majora
Type 3 “infibulation” is the narrowing of the vaginal opening using a seal formed by cutting and repositioning the labia minora/majora, or sometimes through stitching. This can be with or without clitoridectomy.
Type 4 refers to all other harmful procedures to the female genitalia for non-medical purposes such as pricking, piercing, incising, scraping, etc.
FGM/C is mostly carried out in young girls between infancy and the age of 15 years. The procedure is commonly performed by traditional practitioners or “circumcisers” using knives or razor blades, and without anaesthesia (i.e., nothing is given to blunt the pain). Many women who have been subjected to the practice have spoken out about their experiences and I learnt that if you don’t get cut, you’re ostracised (it’s so deep that 7-year-old girls who have been cut refuse to play with their peers who haven’t been). There was also a common pattern of the recollection of events: it’s a ‘celebration’, the girl child is the centre of attention and she never knows why until it’s too late when she’s being held down, having her legs spread forcefully for the circumciser not only to touch her genitals (obviously without consent) but also to cut pieces of it and stitch it up. While the child lies there bleeding, crying from the excruciating pain, the violation of their trust by her caregivers, and the traumatic experience, the women who helped hold her down are celebrating because now the child is ‘clean’ and ‘pure’ - she’s marriageable and her mother hasn’t failed as a parent. The ceremony is now complete, the child’s life is threatened and changed forever but what does it matter? Her parents have earned her (and themselves) a climb up the social ladder, and that’s more important than anything. I know I’m getting ahead of myself but I needed to paint this picture early on.
Protectors and supporters of the practice prefer the term female genital cutting because mutilation is ‘stigmatising’ and ‘judgmental’. I think I prefer mutilation and I’ll be referring to it as such for the remainder of this post.
FGM is a human rights violation
“FGM/C is recognized internationally as a violation of the human rights of girls and women due to the severe health consequences and the pain & risks involved.” - Kaplan et al., Health consequences of FGM/C in The Gambia (2011).
The right to life, health equality and non-discrimination, freedom from inhumane degrading treatment, dignity, and autonomy are some of the rights violated by FGM. Without sugar-coating it, the practice is a severe form of child abuse, sexual violation, and sexual assault. You might be wondering why the right to life is listed here and why I said the child’s life is threatened. From the obvious nature of the practice, FGM doesn’t come without complications and one of them is indeed death (either as an immediate or long-term complication).
What are some of the documented health complications?
Immediate complications (within 10 days of the procedure)
Infection
Excessive bleeding from the wound
Difficulty urinating
Wound healing problems
Death (mostly from the excessive bleeding and/or infection that has spread throughout the body)
Long-term complications (after 10 days)
Chronic pain
Scar tissue
Other infections (urinary tract, vaginal infections)
Painful/difficult urination
Menstrual problems - painful menses (dysmenorrhea), difficulty or inability to pass menstrual blood (seen in Type 3/”infibulation”)
Sexual problems - painful intercourse (dyspareunia), sexual dysfunction including decreased sexual satisfaction
Obstetric problems - increased risk of childbirth complications, excessive bleeding after childbirth (postpartum haemorrhage) which may result in maternal death, death of the newborn
Increased need for later surgeries - e.g., the sealed vagina in type 3 may later be cut open to allow menstrual blood flow out of the vagina, for sexual intercourse, and childbirth
Psychological problems - depression, anxiety, post-traumatic stress disorder, low self-esteem
I have only seen one case of FGM in my clinical years and this was last year during my Obstetrics rotation at Rahima Moosa Mother and Child Hospital (RMMCH) in Johannesburg. It was a young woman in labour, the nurse wanted to put in a urinary catheter but couldn’t find the woman’s urethral opening. She then called me (the only medical student on the floor at the time) and another nurse to assist, but we only saw scar tissue (tissue that forms when a wound heals, like the scar that’s left after cutting your skin) - her urethral opening was sealed shut. I think she might have had Type 1 FGM, I can’t remember. When asked, she told us she peed through her vaginal opening. I was confused and didn’t understand the mechanics of it but decided not to probe further. The nurses told me that this wasn’t an isolated case, they saw a lot of women who have undergone FGM.
According to the article The Knife Between Her Thighs by Shaun Smillie in Curiosity (a research magazine produced by Wits Communications and the Research Office), South African researchers and medical practitioners are seeing more FGM in its most extreme forms. Dr. Marise Subrayan (ObGyn) during the Curiosity interview said she couldn’t do anything to save a newborn baby at RMMCH who had become trapped in vaginal scar tissue and subsequently suffocated to death. The mother’s family had refused a C-section for religious reasons. It has been reported that it’s not only babies at risk, women also bleed to death during and/or after childbirth.
“FGM reflects deep-rooted inequality between the sexes and constitutes an extreme form of discrimination against girls and women. It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person’s right to health, security, and physical integrity; the right to be free from torture and cruel, inhuman or degrading treatment; and the right to life, in instances when the procedure results in death.” - WHO
If there is so much at stake, why is it still practiced?
There are several documented cultural and social factors for performing FGM:
It is the “social convention/norm” and a necessary & non-negotiable rite of passage into womanhood. There are said to be social pressures to conform to what others do and have been doing, otherwise, there’s a risk of being ostracised by the family and community. A woman’s denial or rejection of the practice is culturally taboo.
It is often motivated by beliefs of what is considered acceptable sexual behaviour. It aims to ensure premarital ‘purity/virginity.’ The cultural practice supposedly makes the female genitals ‘clean’ and ‘pure’ until “she’s opened up by her husband.”
Increases a woman’s ‘marriageability.’ Researchers have observed that the importance of a daughter’s marriageability far outweighed the importance of health, consent, and maintenance of body integrity.
Ensures marital fidelity/decreases the possibility of extramarital sex through decreasing desire for sex from clitoridectomy and through painful sexual intercourse.
It is for the ‘beautification of women.’ So mutilation is believed to make women more physically and socially attractive & to make the genitals more attractive.
Now, please allow me to make a quick comparison between the circumcisions of males and females. Both are cultural practices, and rites of passage into manhood (in some cultures) and womanhood. The first stark difference is that male circumcision only entails the removal of the foreskin, which has enormous health benefits, has no impact on sexual desire, and (if done right) is not associated with that many late complications. I know that in some cultures, the boy child is circumcised at birth or infancy while others wait until they turn 18 years old. There may be many reasons for this but I’m not sure informed consent is one of them. FGM is mostly performed in young girls between infancy and age 15. In contrast to male circumcision, the main reason for targeting girl children so young is to prepare them for their husbands by ensuring that they remain ‘pure’ and ‘virgins’ because apparently, no man (who has had multiple risky sexual interactions, by the way) wants to marry someone who is as impure as them.
It is said that the practice makes the female genitals clean and pure until she’s opened up by her husband, and it also ensures that the woman only has sex with her husband because she’ll have such a low libido and will be experiencing so much pain during intercourse that she won’t have affairs. I guess as long as your husband is the one hurting you, all is well. Oh, and your duty as a woman is just to bear children, your body is only good enough to be a vessel so why should you want to have sex? What business do you have enjoying it?
The practice, I feel, solidifies the harmful and outdated narrative that women exist to please men and bear children. I can’t wrap my head around how and why the value of an infant is already equated to how “marriageable” they are/will be, how a girl child’s existence is reduced to making their bodies perfect, clean, and pure for a man to control and use as he pleases. As a vulva owner and as a woman who is in the process of learning how to unleash her sexual power and take agency over her own pleasure, I’m horrified by this practice. It is pure misogyny at play.
“Wait until marriage” - we’re all too familiar with this catchphrase, especially if you were raised in a Christian home. Here’s what we also know: this almost always never applies to our male counterparts. Boys will always be boys, right? In high school, my male classmates who were still fresh out of initiation school used to brag about how they needed to “smash” to sort of cleanse themselves? Meaning now that they were circumcised, their next step in the initiation process was to sleep with a random girl (never their girlfriends for some reason). It's something some grown men used to brag about as well and they even took it a step further by advising the new initiates. So much for waiting to be deflowered on your wedding night!!!
Bringing it back home…
As previously mentioned, we’re seeing more women arriving in South African hospitals who have undergone FGM but there’s been very little research done in SA, and that’s very concerning. Apparently, FGM is practised in some parts of the Eastern Cape, KwaZulu-Natal, and Limpopo. I couldn't confirm this because no one talks about it and I couldn't access the research available.
Many other African countries have introduced programmes and measures to prevent FGM. South Africa is not even recognised by the WHO as a location where FGM is undertaken and that makes it close to impossible to address the growing problem of FGM in the country.
Can we eradicate FGM?
The global attempts to eradicate FGM have been through:
Community education and awareness-raising
Advocacy
Cultural intervention
Laws and policies
Laws and policies. The African Women’s Protocol takes a holistic approach in uniquely addressing the practice in Africa. Article 5 (Elimination of harmful practices) in this protocol is the most relevant to FGM and should be read together with Article 2 (Elimination of discrimination against women) & Article 3 (Right to dignity). I would quote them here, but I think this post is already long 😊.
However, having measures in place to eliminate the practice doesn’t make this a black or white situation. As expected, there’s still some resistance from women of the affected communities; they respond negatively to calls for eradicating FGM, especially when the calls come from outside their communities and cast judgment on their traditions (Omigbodun et al., 2020). So then, until there’s full commitment from the affected communities themselves, it doesn’t matter how many policies are put in place, there’ll never be total eradication of the practice. This is why community education and awareness-raising are also key components to driving change.
Just to finish off, I have attached links to short YouTube videos of FGM survivors sharing their stories:
Well, that brings us to the end of this post. What a difficult thing to write about! I'm glad I saw it through though because I learnt a lot and I hope you did too. Thank you for your time, we will hopefully meet here again to learn something different. Enjoy the rest of your week!
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