Clitoridectomy and infibulation, commonly known as female circumcision, are practices found in many African cultures. The reasons for their development are not known. They are deeply embedded, however, in cultures where they occur because they affect the very definition of what it is to be female. Many Africans and Westerners feel that the practices are harmful but efforts to eradicate them cannot be divorced from the total cultural, and political context. This paper describes some of the recent work on female circumcision and makes suggestions for further research and eradication efforts.

Genital and ritual surgery are terms which may be used for a wide variety of surgical procedures performed on human genitalia in dozens of different societies and ethnic groups throughout the world. The procedures range in severity, or distortion of the original anatomy, from the subincision practiced in some Australian aboriginal groups, in which the penis is subincised or slit on the underside as far as the urethra, to the mildest form of female "circumcision," practiced in several countries in Africa, in which the prepuce of the clitoris is removed to expose the clitoris itself. The ages of the people on whom ritual surgery is performed varies, from the usual practice in U.S. hospitals of circumcising newborn males to the reinfibulating, or sewing together of the labia, of adult African women after they have borne a child. In some cultures, particularly in West Africa, ritual genital surgery is performed as an initiation rite on young people as a group; in other cultures, the event is an individual one marked with little celebration.

The very choice of a term by which to refer to the subject under discussion is a political act. "Genital mutilation" is the term used by Fran Hosken, the person who has published the greatest number of articles on the subject of ritual genital surgery on women. She asserts that the term frequently used in the literature in the past - "female circumcision" - is in reality inappropriate, since circumcision of males leaves the entire penis intact while female circumcision usually involves the removal of the entire clitoris. Other more anatomically accurate terms frequently used for clitoral ablation are "excision" and "clitoridectomy;" "infibulation" is the term used for the removal of the labia minra and the inner surfaces of the labia majora and the sewing together of the remaining tissue so that only a small hole for the passage of urine and menstrual blood remains.

The Sudan is a country in which all the various kinds and degrees of female genital surgery are practiced, and so it may be useful to examine the situation there in some detail. Asma El-Dareer, a Sudanese physician, was chosen by the Faculty of Medicine in Khartoum to do a study within the Sudan of the prevalence of ritual surgery of females, to identify and describe the types of surgery practiced, and to investigate the attitudes of people of various ages toward the custom. She was able to interview over 3,000 women in five different provinces of the Sudan. The study area had a female circumcision prevalence of nearly 99 percent. Of these, 80 percent were Pharaonic circumcisions - the oldest historically and the most severe form which the practice takes in the Sudan. In Pharaonic circumcisions, as performed by traditional midwives, the entire clitoris is removed from the base, the labia minora are grasped with the hand and cut off, the inside edges of the labia majora are excised, and then the two sides of the wound are brought together and held together by various substances (egg and cigarette papers in the Eastern Sudan; thorns used as skewers in the Northern Sudan) until they close and heal, forming a smooth area of epidermis over the outside with a midline scar. The girl's legs are bound together tightly at the ankles, knees, and thighs to prevent her from moving, so that the healing edges of the wound will not be disturbed; the aim is to make the opening into the vagina as small and tight as possible. It usually takes between 15 and 40 days for the wound to heal completely. Pharaonic circumcision is also performed by trained midwives with modern surgical techniques, including the use of catgut or silk to stitch the edges of the wound together.

In 1945 the British government outlawed Pharaonic circumcision in the Sudan, and urged the Sudanese to practice "Sunna" circumcision. Sunna means "tradition" in Arabic, and this form of female circumcision is said to have been recommended by the Prophet; it is also called "Government Sunna." Sunna circumcision consists of removing only the prepuce from around the glans of the clitoris, and thus is homologous to male circumcision. In El-Dareer's sample of 3,000 women, only 2.5 percent had had this kind of operation. Both trained and lay midwives perform Sunna circumcision.

When the British outlawed Pharaonic circumcision and urged the Sudanese to practice Sunna circumcision, they did not realize that for many ethnic groups in the Sudan Sunna circumcision was considered to be no circumcision at all. An operation intermediate between Pharaonic and Sunna circumcision was invented by trained midwives as a compromise between the demands of the government and of their clients. This intermediate kind of operation covers a wide range of variation. In the mildest form of intermediate, only the tip, or at most half of the clitoris is removed, and the surfaces of the labia minora are roughened and then stitched together. The most severe grade of intermediate circumcision is nearly indistinguishable from Pharaonic, and involves the removal of the clitoris, anterior parts of the labia minora, and parts of the labia majora, and the stitching together of what is left, leaving an opening of variable size. Midwives consider the intermediate type in which the labia are left intact but are sewn together to be the Sunna type recommended by the Government and by the Prophet.

The following tables from El-Dareer's book summarize features of the Sudanese practice of female circumcision:

Table 1 - Types of Circumcision by Area

Inter

Sunna mediate Pharaonic

Urban 37 (47%) 310 (80%) 1,178

(45%)

Rural 39 (49%) 76 (20%) 1,452

(55%)

Unknown 4 (4%) (-) 6 (0%)

Use of Anesthesia

Anesth. used 25 (31%) 307 (79%) 634 (24%)

Not used 53 (66%) 72 (19%) 1,999

(76%)

Unknown 2 (3%) 7 (2%) 3 (0%)

Use of Antibiotics

Antib. used 29 (36%) 211 (55%) 549 (21%)

Antib. not used 45 (56%) 168 (43%) 2,081

(79%)

Instruments used,/P>

Sharp stones 6 (7%) (-) 13 (0%)

Knives 31 (39#) (-) 1,170

(44%)

Razors 20 (25%) 87 (22%) 837 (32%)

Scissors 18 (22%) 242 (63%) 460 (18%)

Unknown 5 (7%) 57 (15%) 156 (6%)

(El-Dareer 1982:5-6)

Slightly over I percent of the sampled women were Coptic Christians; all of them had been circumcised with a Pharaonic operation, thus belying the idea that female circumcision is a Muslim custom. Nevertheless, it cannot be denied that in the Sudan a strong belief exists that circumcision is recommended by Islam.

In the urban areas, the operations performed are mostly of the intermediate type and are performed primarily by trained midwives, usually with anesthesia; in the rural areas circumcision is usually performed by traditional midwives, but a small percentage (3 percent) are performed by old women who inherited the role of circumciser from their own mothers. Doctors and nurses perform 2 percent of all circumcisions, of which more than half are Pharaonic. The age at which girls are circumcised varies among the different ethnic groups of the Sudan; eastern groups such as the Beja circumcise their girls when they are from 7 to 40 days old, while 6 to 8 years of age is common among most other ethnic groups; 95 percent of the children in the sample had been circumcised by 11 years of age. One ethnic group originally from West Africa, the Fallata, do not circumcise; when people were asked why they do not abandon the practice of circumcision, they reply, "We are not Fallata!" When non-circumcising ethnic groups move to the cities and come into contact with those who do circumcise, they adopt the practice and begin to circumcise their daughters so that they won't be laughed at. In some southern tribes, women from chiefs' families undergo a more severe circumcision than commoners.

In Asma El-Dareer's survey, the reasons given for continuing the practice of circumcision were, in order of decreasing frequency: tradition, religion, cleanlinesss and beauty (uncircumcised genitalia were described as ugly and dirty), better marriage prospects, greater pleasure for the husband, preservation of virginity/prevention of immorality; and increased fertility. Those who reject female circumcision gave as their reasons complications during marriage and labor, religion (respondents said it was contrary to the teaching of Islam), failure to achieve sexual satisfaction, personal experiences, human/women's rights, and fear of infertility.

The Sudan is a large and pluralistic country in which the practice of female circumcision is changing rapidly. The more educated people are giving up the practice, at the same time as rural people moving into urban areas are adopting the custom from other ethnic groups. It is not known to what extent the Sudan's experience is relevant for any other countries where female circumcision is practiced; nonetheless, the difficulty the Sudanese are experiencing in their attempts at eradication is probably universal. The zeal with which some health professionals pursue the goal of eradication is born out of their experience with the sequelae of female circumcision as they come to the health care system. We need to examine briefly some of these medical complications before going on to look at the distribution of the practice of female circumcision throughout the world.

The immediate complications of circumcision are: damage to the urethral meatus, Bartholin's glands, and even the perineum and rectum (the latter usually from struggling on the part of the child and inadequate instruments); hemorrhage; shock; difficult urination; retention of urine; fever; infections of the external genitalia, vagina, and ovaries and uterus; and arthritis. Long-term effects include difficult (because partially obstructed) menstruation; urinary tract infections; vulvar abscesses; epidermoid inclusion cysts; keloids; difficult penetration by the sexual partner; dyspareunia; lack of orgasm (among women with all types of circumcisions in a study done in the Sudan, 41 percent were orgasmic, compared to 75 percent of the women in Kinsey's American sample; in another larger study done in the Sudan, 80 percent of women with Pharaonic circumcisions had never experienced orgasm; and obstetrical complications. The latter entail risks to both the mother and fetus and include prolonged labor, perineal and deep trauma, rupture of the uterus, and fetal death or brain damage. Circumcision makes normal delivery impossible, because the vulva and perineum are replaced by scar tissue, which is much more inelastic, and thus episiotomies are absolutely essential especially for women with Pharaonic circumcisions. Effects which are specifically psychological have been given much less attention in the literature, probably because such information is much less accessible to foreign health professionals; one of the few by foreigners is that by Leberblad done in the Sudan. Social scientists and health workers who are insiders in the cultures practicing female circumcision, such as El-Dareer in the Sudan and Abdalla in Somalia, are leading the way in documenting the psychological effects of the custom.

The history of ritual genital surgery on women is not well known. Reliefs showing male circumcision being performed have been found in Egypt and have been dated as being from the sixth dynasty or 2340-2180 B.C., but whether excision and infibulation had a parallel development is unclear. But by the time of the first millennium B.C. there is considerable evidence that female clitoridectomy and infibulation was also practiced in Egypt. Herodotus mentions the custom specifically and tells us that it was practiced by the Phoenicians, Hittites, and the Ethiopians as well as the Egyptians. In the 1st century B.C. Strabo, another Greek historian and geographer, travelled up the Nile and reported that the Egyptians circumcised their boys and excised their girls. Remondino reports a number of other confirmations of the presence of the custom in ancient Egypt. Two Greek physicians who visited Egypt, one in the second and one in the sixth century A.D., described the operation, and both stated its purpose as the reduction of female sexual desire caused by the enlargement of the clitoris from its rubbing on the women's clothing.

As Islam spread into Egypt during the Arab conquest of North Africa, the practices of clitoridectomy and infibulation were picked up and carried to distant parts of the world. This ultimately led to the present rather ironic state of affairs, in which those people who practice ritual genital surgery on the periphery of the worldwide distribution - those in Mali and Indonesia, for example - tend to perceive it as a custom which is Muslim, while at the same time excision and infibulation are not practiced in the areas of the Arabian peninsula near Mecca and Medina. (They are, however, common in the southern part of the peninsula, as is the custom of placing salt in a woman's vagina after childbirth to insure its tightness.

On the continent of Africa itself, clitoridectomy and infibulation are practiced in the Sudan (which has already been examined in some detail); in Somalia, where the practice is nearly universal and includes ethnic Somalis living in the neighboring states of Djibouti, Ethiopia, and Kenya; in Egypt; among Muslim groups in Mali, Central African Republic, Nigeria, and Ethiopia. Excision alone is reported to be practiced in more than a dozen African countries: Egypt, Sudan, Ethiopia, Kenya, Tanzania, Zaire, Central African Republic, Cameroon, Chad, Libya, Niger, Nigeria, Dahomey, Togo, Ghana, Upper Volta, Ivory Coast, Liberia, Sierra Leone, Guinea, Gambia, Senegal, Mauritania, and Algeria.

In Asia, ritual surgery of females is not commonly practiced. It is reported in Malaysia, Indonesia, the Arabian Peninsula and the Persian Gulf (The United Arab Emirates, Oman, Bahrein, and South Yemen), Pakistan, and Russia (only a few ethnic groups). In South America, there have been reports of its practice in Peru, Brazil, and eastern Mexico (Worsley 1938); and the practice exists in Australian aboriginal groups.

It may perhaps be useful to review some of the attempts that have been made in the past to offer a general theoretical formulation for the practice of clitoridectomy and infibulation. Two general perspectives have been used by most writers: a Marxist perspective, and a psychoanalytic approach. The Marxist/feminist viewpoint utilizes the general approach of Godelier in his application of Marxist theory to African settings. He asserts that in pre-industrial African societies the primary resource is labor, and thus the control of production is effectively the same as the control of reproduction. In societies practicing infibulation, the sewing up of a young girl's vagina insures that her reproductive capacity will be safely secured until it can be incorporated into the lineage system of exchanges of women for bridewealth. Clitoridectomy can similarly be accounted for; it functions to dampen down the sexual desire of women so that it can be controlled and utilized in the service of the production of children - the new labor supply of the society. This theoretical viewpoint has been well stated by Nawal El-Sadaawi in her book The Hidden Face of Eve about the role of women in Egypt, and by Raqiya Haji Dualeh Abdalla in her book Sisters in Affliction about the practice of clitoridectomy and infibulation in Somalia.

Another interpretation of clitoridectomy and infibulation is also possible, and that is that the custom may have the function of lowering the fertility of women in areas where, because of either desert conditions or high population density, the land is nearly at carrying capacity. Such an explanation could also be incorporated into a Marxist framework, and could be tested in a well-designed cross-cultural survey using existing ethnographic data.

Other writers have offered explanations of clitoridectomy and infibulation using a psychoanalytic framework. Psychoanalytic interpretation is not inconsistent with a Marxist perspective, since all historical developments and synchronic states are mediated by the thoughts and actions of individuals. Joel Kovel's book White Racism might perhaps serve as a model of the integration of the two theoretical frameworks, but Bruno Bettelheim's older but excellent work. Symbolic Wounds, is a good starting point for an examination of the contributions of psychoanalytic theory to the problem of both male circumcision and clitoridectomy and infibulation. Bettelheim concludes after extensive examination of the world ethnographic corpus that initiation rites, including circumcision, should be viewed within the context of fertility rites. He feels that initiation rites of both boys and girls may serve to promote as well as to symbolize full acceptance of socially prescribed gender roles. He sees male circumcision as perhaps not only symbolizing the threat of paternal castration of the sons but also as an assertion that men too can bleed and hence menstruate and bear children. The removal of the foreskin, he says, may also cause the penis to look as if it is in a constant state of erection and thus enhance males' phallic narcissism. Clitoridectomy and infibulation may have arisen from a need to have a rite for women analogous to male circumcision, but it may also express men's ambivalence about and/or envy of women's sexual and childbearing functions. He points out that clitoridectomy and infibulation are never practiced without comcomitant male circumcision. And he makes clear that the practice of male circumcision in infancy is a radical departure from traditional African practice: "Initiatory circumcision is not the same as its imposition on a helpless infant, to whom it does not offer any advantages, and to whom it is thus undesirable and threatening" . He cautions those who study initiation rites not to forget the cultural context: "The emotional reaction to an event depends to a considerable extent on how the person has been prepared for it, on the anticipations which he brings to it, and on his a priori expectations of its consequences". He summarizes with the broad generalization that pre-state societies use autoplastic means to deal with anxiety and ambiguity - i.e., they clarify gender roles by operations on the human body - by male circumcision, which enhances the phallic appearance of the penis, and by clitoridectomy and infibulation of women, which insures that their primary role will be a reproductive one, and one in the service of the existing societal structure. (Ghalioungui's informants explained male and female circumcision in almost these terms: that male circumcision removes the female aspect of boys - the damp and smegma-producing foreskin - while excision of girls removes the phallic or male-like aspect of women's sexual anatomy. Bettelheim ends his book with a plea for a different way of dealing with sexual ambiguity:

On a more human level, if we could satisfy...the desires of both men and women to participate in the activities and enjoyments normally belonging to the other sex, each sex could gain greater inner autonomy, could better accept its own role and that of the other; the two could live with one another more satisfactorily. In preliterate society, it seems, men tried to solve this problem through ritual. We should be equally serious in our own efforts, searching for solutions that are more rational, more effective socially, and more satisfying privately (Bettelheim 1954:265).

If an individual or group should decide that they cannot hold a cultural relativist position about the clitoridectomy and infibulation of women, what should we do? Clitoridectomy and infibulation exists today in a geopolitical context that is littered with land mines awaiting the culturally insensitive. But perhaps some steps can be taken.

Eradication of the practice of clitoridectomy and infibulation from Africa has to be accomplished mainly by Africans. At the conference held in Khartoum in October 1984, Africans from 14 countries gathered to share information about in-country activities, successes and failures, and to plan strategies for the future.

Out of the Khartoum conference was formed the Inter-African Committee on Traditional Practices which has its headquarters in Geneva. It was the sense of the conference that there was no dearth of things for non-Africans to do. They can collaborate with individual Africans on research and education projects, collect bibliographies, assist with fundraising, and perform other activities which are made easy by their access to the electronic, computerized information world.

The current approach to effecting change in the practice of female circumcision by most Africans working in this area is to widely publicize the consequences of female circumcision and this by itself, it is hoped, will lead to change. I find this somewhat discouraging because I know that knowledge of the health consequences has not led, in the U.S., to the elimination of male circumcision, cigarette smoking or nuclear weapons. These harmful practices and objects continue for political/economic reasons, to be sure, but they also persist because human beings are not rational. They are motivated by complex unconscious processes. I am sure it is not otherwise with clitoridectomy and infibulation.

All efforts which are undertaken should be done in the sense of the old medical recommendation: primum non nocere: the most important thing is to do no harm. It is, therefore, with some trepidation that I have begun to interview East African women who are willing to talk to me about their experiences with clitoridectomy and infibulation. Some aspects of any cultural practice are more easily revealed to an outsider under circumstances of confidentiality. I am a special kind of outsider because of twenty years of association with Somali culture.

One thing apparent in the few interviews that I have done so far is the importance in the urban areas of Somalia of peer pressure. Somali girls used to be operated on when they were seven to eleven years of age; now there is a great deal of pressure for girls to be circumcised before entering primary school. Uncircumcised girls will be called buriya qab by their peers - buriya means "clitoris" and qab means both literally "to hold onto" and more metaphorically "to retain, keep." The taunt thus has a wide range of meanings from "you hold onto your clitoris" (i.e., you masturbate) to "you are too weak to give up your clitoris."

Another important finding is that, while a Marxist/feminist interpretation is perhaps a useful way to look at the historical evolution of female circumcision, it may not be the best paradigm for eradication efforts. In urban Somali families today, men are generally the ones who are pressing for elimination or mitigation of clitoridechtomy and infibulation, while mothers, grandmothers, and traditional practitioners - who collect a fee for performing the operations - are the ones resisting change. This may be because men have had broader sexual experience and/or more time in the West. The role of African men in effecting change must not be overlooked.

To conclude, then, there is a need for broad survey research in many areas of Africa to identify cultural constructs and ideological paradigms about circumcision to further elaboration the bio-medical consequences of female circumcision (such as infertility) and to discover for each society what kind of eradication programs will be effective. Surveys like the one which had been done in the Sudan, in conjunction with broad surveys, are needed clarify the attitudes, hopes and fears of the people involved. Out of such in-depth research might come totally new hypotheses about the function of the custom and new ideas for action. Everyone - African and Western, male and female - should think carefully about whether they have anything to contribute to this issue, and if they feel that they do they must not let the geopolitical context in which clitoridectomy and infibulation now exists deter them from work in this area. If they are sincere and culturally sensitive, there will be a role for them no matter what their color, nationality or gender.

Culture is a complex homeostatic system, and to change one aspect of it is, in some sense, to change everything. All change is stressful, and while the needs of girls who have not yet been circumcised must be considered, the implication of change for the self-esteem of mothers must not be forgotten.

Nevertheless, culture contact, and thus a complete change in the context in which clitoridectomy and infibulation takes place, will not go away; each year there are fewer and fewer people (no matter where on the earth they happen to live) with the world view of an old Somali nomad woman, who, when told by the Western interviewer through an interpreter that there were some cultures in which women were not circumcized, said, "That's too bad; I am sorry for them."

Most Africans from circumcizing cultures have no orientation about US attitudes toward the practice before they arrive in this country. They certainly know nothing about the legal implications of performing female circumcision here. The culture contact situation can be very confusing for these new arrivals. East African women visiting the US have to use the American health care system, and must undertake the task of educating their physician about their special gynecological and obstetrical needs in the context of a 30 minute office visit and physical exam. Soon, in the US a situation may arise like one which recently occurred in France when a West African man was indicted for homicide after his daughter died from complications of her clitoridectomy.

In the context of culture change, to say or do nothing is, in fact, to do something. Everyone can contribute something, if only empathy and understanding for those who have to make difficult decisions - those who are personally affected by the practice. Bettelheim's wish that we all would find effective ways of dealing with ambiguity and anxiety was never so applicable as it is to the cultural practice of clitoridectomy and infibulation in its global context.

Article copyright Cultural Survival, Inc.