Recently, Medical News Today published a story on the practice of male infant circumcision. The article hinged around new claims as to the benefits of male infant circumcision made by the Mayo Clinic and the controversial researcher Prof. Brian Morris. Although we included alternative viewpoints via the criticisms of the anti-circumcision group The Whole Network, the article generated lively commentary from our readers. One reader compared the issue of male infant circumcision to that of what was once called “female circumcision,” but which is now more routinely described as “female genital mutilation” (FGM). FGM encompasses the removal of the clitoris, sealing of the vaginal opening and other interventions aimed at restricting sexual activity in girls and women. It causes physical and psychological harm that can be extremely severe, often irreversible and even fatal. “As FGM is not practiced in the west,” commentator Sarah Robinson wrote, “we are biased against seeing benefit, and minor females are protected from genital mutilation under the law. Unfortunately this protection is not extended to infant boys.” Prof. Brian Morris rejected this argument, telling Medical News Today that: “…so-called ‘female circumcision’ is a misnomer, and is not equivalent anatomically to the male procedure. If it was, then the whole penis would be lopped off. And female genital cutting has no medical benefit, only harms, as any informed person would know. Trying to equate the two is another mischievous tactic of opponents.” Both physicians and campaigning groups have strived to untangle FGM from the debates around male infant circumcision, which remains a popular procedure in many countries – not least of all the US – due to its perceived medical benefits. By contrast, FGM has never been associated with benefits to the health of the circumcised female. The procedure is performed for traditional reasons among some cultures – especially in rural East Africa. The reasons for and against it are complex and deeply enmeshed with conflicting ideas about gender roles and social values. Western engagement with communities who practice FGM is delicate and fraught. Attempts at reform move slowly and are prone to backfiring.

Why is FGM under scrutiny right now? Despite the repositioning of FGM within global discourse as a human rights rather than a health issue, Medical News Today is using this Spotlight feature to examine recent research and policies investigating FGM and the communities who enforce it. Countries with highest prevalence of FGM Somalia – 98% of girls and women

Guinea – 96%

Djibouti – 93%

Egypt – 91%

Eritrea – 89% FGM is currently a hot topic in the UK, whose government recently launched its first inquiry in how to end the practice in Britain. Media coverage of FGM in the UK has alerted the public to the pervasiveness of this practice – often thought of as an arcane tradition existing only in isolated pockets of the globe. For instance, 140 million women worldwide live with the consequences of FGM and estimates suggest 66,000 of these are in the UK. Sources also report that nearly 4,000 women and girls have been hospitalized in London for FGM since 2009. In March, the British Director of Public Prosecutions announced the first ever prosecutions under the Female Genital Mutilation Act – a law that has been in place since 1985. Media in the US reporting on the developments in the UK have largely framed the issue as an immigration debate. However, on April 18th this year, the Bureau of Public Affairs announced the Gender Based Violence (GBV) Emergency Response and Protection Initiative. “Under the leadership of President Barack Obama,” the release announced, “the United States has put gender equality and the advancement of women and girls at the forefront of US foreign policy.” The GBV Initiative aims to tackle FGM, along with early or forced marriage, “honor” killings, female infanticide, child sexual abuse and sex trafficking, among other forms of gender-based violence. Although the policy is unclear as to what extent these problems will be tackled within US borders – or even if FGM is considered a homeland issue at all – it does promise short-term assistance for survivors and targeted training and advocacy in 11 “hub countries” across the Middle East, Africa, South and Central Asia and Latin America. The GBV Initiative is one of several international campaigns to attempt community engagement in global regions where FGM is endemic.

Are illegalization and health-focused FGM awareness campaigns helping? Although some headway has been made in terms of reform in countries with centuries-old traditions of FGM, a forthcoming report from World Vision – the world’s largest international children’s charity – on how communities are responding to these reforms is not encouraging. In Kenya and Ethiopia, for instance, FGM is now illegal. But rather than driving down incidence of FGM, World Vision suggests that the practice has simply been driven underground. The consequence is clandestine circumcisions performed by unexperienced practitioners, with increased health risks to the girls involved. Obstetric risks of FGM There is a 70% increase in postpartum hemorrhage among infibulated women, compared with women with no FGM.

Infibulated women will have on average 30% more C-sections than those who have not had any FGM.

Death rate among babies born to infibulated mothers is 55% higher than babies born to mothers without FGM. Awareness campaigns focusing on the health risks of FGM in Somaliland, meanwhile, have been successful in moving communities away from the extreme practice of infibulation – where the clitoris is removed and the vagina is sealed in such a way as to make intercourse impossible (the seal is cut open after marriage for the purpose of producing children). However, it has been replaced instead not by a renouncement of FGM, but by clitoridectomy – the amputation of the clitoris. A renewed pressure is said to now be placed on marrying girls young in these countries, as infibulation was believed to be necessary in preventing premarital sex. Throughout FGM-practicing countries, preserving the marital legibility of the community’s daughters is seen as paramount, and the various forms of FGM have long been considered essential tools in this. Girls who are not circumcised in such communities are not only seen as being more sexually available – and therefore not suitable for marriage – but they are often excluded and subjected to violence. In a 2010 report, the international children’s rights campaigning body UNICEF explains that FGM is not viewed as a violation in FGM-practicing communities, but as a means of protecting their daughters, “and to give them the best possible chance to have a future that will ensure social acceptance and economic security.”

FGM ‘violates women’s right to health, security and physical integrity’ Share on Pinterest FGM is not viewed as a violation in practicing communities, but as a means of giving their daughters “the best possible chance to have a future that will ensure social acceptance and economic security.” However, in the same report, UNICEF make their position clear that FGM violates women’s right to health, security and physical integrity, their right to be free from torture and their right to life when the procedure results in death. Though not intended as violent, FGM “is discriminatory in nature, and assigns girls and women an inferior position in the family and society,” the report reminds. This presents unique problems in educating communities and suggesting alternative rites of passage that could replace this harmful practice. UNICEF stresses that this process must not begin with individuals, but with a core group who will be able to disseminate change through their community until a large enough proportion of the intermarrying community is ready to abandon FGM. For this to be successful, they argue, community members must be rewarded for not cutting their daughters and sanctioned if they do. And it is essential that the community is able to trust the facilitators of change.

Building FGM into general community-wide debates about sexual health and gender roles In a region of Ethiopia, an organization formed by a pair of local sisters who had been circumcised – KGM-Ethiopia – facilitated this change successfully with a novel approach. In 1997, when KGM began to engage their local region, a fear of AIDS was endemic in Ethiopia. Community leaders wanted to know how to halt the terrifying spread of the disease across their country. KGM organized “community conversations,” where one man and one woman nominated by each village would be trained by KGM – and paid $4.50 a month – to lead a debate involving a variety of 50 community members each week. The conversations began with sexual health, which led into discussion of power in relationships, then gender rights and, finally, FGM and its associated dangers. KGM also invested in the communities. They built bridges, supplied health services, planted trees and built schools. By 2004, the marriages of uncircumcised girls in this region had turned into huge celebratory affairs, with event attendance reaching hundreds of thousands. Over a period of 9 years, public support for FGM in Kembato-Tembaro – the region where KGM began their training – was reported as having dropped by 97%. World Vision have also reported some success with similar community engagement tactics – such as obtaining pledges from former circumcisers to abandon the practice in exchange for a gift of some goats to provide them with alternative means of earning a living.

Can FGM be reversed, surgically? Share on Pinterest Anti-FGM campaigners argue that boys and men need to be as involved in the debate as the girls and women that these campaigns strive to help. Other Westernized anti-FGM initiatives have been less successful at engagement, however. A clinic in Burkina Faso – “Clitoraid,” which opened in March – claims to be able to reverse the effects of clitoridectomies and infibulations. But the science employed by the clinic – pioneered by the French urologist and surgeon Pierre Foldès – is viewed with suspicion by the medical community. In 2012, Foldès published his research (resource no longer available at press.thelancet.com) – claiming that full clitoral sensation could be restored in less than an hour – in The Lancet, but the small sample size and self-devised metrics drew heavy criticism. The Lancet later published a dismissal of Foldès’ claims by a team of experts. The name “Clitoraid” is part of an epic rebranding exercise. The clinic was originally named “The House of Pleasure” and was advertised by handing out free sex toys to the deeply conservative people of Burkina Faso. It had been partly funded by collecting donations at adult entertainment venues in the West. Promoting an ideal of free love and sexual liberation, the group’s engagement strategy could not have been more heavy-handed and at odds with the religious communities they were purporting to help. An “Adopt a Clitoris” campaign also proved unpopular. The rebranding also now masks the clinic’s origins; it is a surgical wing of the Raëlian Movement, a UFO religion founded by a former sports car journalist and French pop singer, Claude Vorilhon (now known as Raël), who claims to be the son of an extraterrestrial named Yahweh.