FEMALE GENITAL MUTILATION:

STRATEGIES FOR ERADICATION Fran P. Hosken Presented at The First International Symposium on Circumcision, Anaheim, California, March 1-2, 1989.

Female genital mutilation - the descriptive term for the different types of operations are "excision" and "infibulation" - continues to be practiced in large regions of Africa, from the Red Sea Coast to the shores of the Atlantic. According to a conservative estimate, at least 84 [110] million women and girls are mutilated today in Continental Africa and similar operations are practiced along the Persian Gulf and the southern part of the Arab Peninsula. In Indonesia and Malaysia, less drastic forms of "female circumcision" are practiced by some of the Moslem populations of this region and sporadic occurrences have been registered among other mainly Moslem groups.

With increasing mobility of African and Middle Eastern immigrants to Europe, the U.S. and also to Australia, these mutilations are being exported all over the world. Indeed, Britain had to pass special legislation recently to prohibit the operations (which were carried out by obliging physicians for a high fee). In France, the Criminal Courts had to finally initiate proceedings against African fathers and families after three little girls died as a result of the operations performed in France. One father brought to court had "operated" on his baby daughter with a pocket knife - the child bled to death.

In most European countries and also in Australia, health services have been alerted to warn people and especially immigrants. In the U.S., immigrants from affected African countries have not been warned by immigration services that these mutilations are categorized as gross child abuse and would result in having children removed from parents by the Social Services. There is no doubt, and anecdotal evidence exists, that immigrants from Somalia, Sudan, Ethiopia, or certain ethnic groups of Kenya, Nigeria, etc., are having their small daughters mutilated in the U.S.

A systematic survey has yet to be done to document the facts on how many children are involved or are at risk - and this is long overdue (see below).

But first, the medical and health facts need to be established.

The medical literature describes "circumcision" or "sunna circumcision" as the removal of the clitoral prepuce and the tip of the clitoris. "Sunna" means tradition in Arabic. But to remove the prepuce of the clitoris, which is a very delicate operation especially if done on a child, would require great skill, good light, surgical tools, an anesthetized, motionless body, quite aside from a thorough knowledge of anatomy.

None of these conditions exist where these operations are done in Africa and the Middle East on struggling, screaming children held down by force on the ground in dark huts, with crude knives or any other cutting tools. What is done in reality is cutting away whatever the operator can get hold of, part or all of the clitoris and often part of the labia minora (small lips).

Excision or clitoridectomy, the operation most frequently done throughout Africa, consists of the removal of the entire clitoris, usually together with the adjacent parts of the labia minor (small lips) and sometimes all of the external genitalia, except parts of the labia majora (large lips). Some operators make additional cuts to enlarge the opening of the vagina as this is believed to make childbirth easier. (The opposite is true.)

Infibulation or pharaonic circumcision (excision with infibulation) means that the entire clitoris and the labia minora are cut away and the two sides of the labia majora are partially sliced off or scraped raw and then sewn together, often with catgut. In Sudan and Somalia, thorns are used to hold the two bleeding sides of the vulva together, or a paste of gum arabic, sugar and egg is used. The introitus or entrance to the vagina is thus obliterated which is the purpose of the operation, except for a tiny opening in the back to allow urine, and later menstrual blood, to drain. The legs of the girl are tied together immediately after the operation, and she is immobilized for several weeks until the wound of the vulva has closed, except for a small opening that is created by inserting a splinter of wood or bamboo.

The mortality of girls and women due to all these operations no doubt is high; but no records are kept anywhere. Primary fatalities are not recorded and death in childbirth due to obstructed labor is never related to genital operations anywhere. But the terrible psychological trauma that is lifelong has never been investigated from a woman's view.

The objective of infibulation is to make sexual intercourse impossible. At present, infibulation is practiced mostly by Moslems, according to all available sources, because of the importance and value they attach to virginity. Infibulation is performed to guarantee that a bride is intact - the smaller her opening, the higher the bride price. A girl is often inspected by the female relatives of the husband-to-be before the bride price is paid. The bride price, whereby the husband or his father pays the father of the girl a considerable sum in cash or kind, is still a marriage requirement almost everywhere in Africa and the Middle East.

Infibulation may also occur spontaneously by adherence of the wounded sides of the labia, especially where extensive excision operations are performed. For instance, in parts of Mali and Burkina Faso as well as other areas of West Africa.

Women who are infibulated have to be cut open to allow sexual intercourse and more cuts are needed for delivery of a child Wives, traditionally, are re-infibulated, for instance in the Sudan, after the baby is born; and when the child is weaned, they are opened again for intercourse. During her reproductive life, a woman used to go through this process with each child; and in some areas it still continues today.

In West Africa, infibulation is usually not done by sewing or other fastening devices; but, by tying the legs of the girl together (after the operation) in a crossed position, the same results are achieved. On a visit to Ouagadougou, Burkina Faso, in 1977, while I was at the maternity hospital, a woman in labor with her first child was brought in; she could not deliver; she was almost completely closed. There was nothing at all left of her external genitalia. She had evidently conceived through a tiny opening.

All the operations are performed on the ground, under septic conditions, with the same knife or tool used on all the girls of a group operation, which is still the custom among many ethnic groups in rural areas. In cases of fatalities, neither the operator nor the operation are ever blamed. Rather, it is claimed that an evil spirit is responsible or the ritual was not performed properly according to the wishes of the ancestors - or the girl herself is at fault because she had sex before she was operated on.

Infibulation or pharaonic circumcision is practiced in the Sudan and adjoining areas throughout Somalia, parts of Ethiopia, Southern Egypt and Northern Kenya and in some areas of West Africa, for instance, Mali. Infibulation or pharaonic circumcision is the most drastic and damaging operation. It is called "Pharaonic" as the operation, according to historic documents, was already recorded in ancient Egypt more than 2,000 years ago in Pharaonic times.

The term infibulation is derived from fibula, which means clasp or pin in Latin and goes back to the old Romans; a fibula was used to hold together the folds of the toga - the loose garment all Roman men wore. The Romans also fastened together the large lips of slave girls to prevent them from having sexual intercourse as becoming pregnant would hamper their work.

Here is an eyewitness description of an operation in Somalia:

"With the Somalis, the circumcision of girls takes place in the home among women relatives and neighbors. The grandmother or an older woman officiates. At each occasion, usually only one little girl or at times two sisters are operated; but all girls, without exception, must undergo this mutilation as it is a requirement for marriage. "The operation itself is not accompanied by any ceremony or ritual. "The child, completely naked, is made to sit on a low stool. Several women take hold of her and open her legs wide. After separating her outer and inner lips, the operator, usually a woman experienced in this procedure, sits down facing the child. With her kitchen knife, the operator first pierces and slices open the hood of the clitoris. Then she begins to cut it out. While another woman wipes off the blood with a rag, the operator digs with her sharp fingernail a hole the length of the clitoris to detach and pull out the organ. The little girl, held down by the women helpers, screams in extreme pain; but no one pays the slightest attention. "The operator finishes this job by entirely pulling out the clitoris, cutting it to the bone with her knife. Her helpers again wipe off the spurting blood with a rag. The operator then removes the remaining flesh, digging with her finger to remove any remnant of the clitoris among the flowing blood. The neighbor women are then invited to plunge their fingers into the bloody hole to verify that every piece of the clitoris is removed. "But this is not the end. The most important part of the operation begins only now. After a short moment, the woman takes the knife again and cuts off the inner lips (labia minor) of the victim. The helpers again wipe the blood with their rags. Then the operator, with a motion of her knife, begins to scrape the skin from the inside of the large lips. "With the abrasion of the skin completed, according to the rules, the operator closes the bleeding large lips and fixes them one against the other with long acacia thorns. "At this stage of the operation, the child is so exhausted that she stops crying, but often has convulsions. The women then force down her throat a concoction of plants. "The operator's chief concern is to leave an opening no larger than a kernel of corn or just being enough to allow urine, and later the menstrual flow, to pass. The family honor depends on making the opening as small as possible because with Somalis, the smaller the artificial passage is, the greater the value of the girl and the higher the bride price. "When the operation is finished, the woman pours water over the genital area of the girl and wipes her with a rag. Then the child, who was held down all this time, is made to stand up. The women then immobilize her thighs by tying them together with ropes of goat skin. This bandage is applied from knees to the waist of the girl, and is left in place for about two weeks. The girl must remain lying on a mat for the entire time, while all the excrement evidently remains with her in the bandage. "After that time, the girl is released and the bandage is cleaned. Her vagina is now closed, and remains so until her marriage. Contrary to what one would assume, not many girls die from this torture. There are, or course, various complications which frequently leave the girl crippled and disabled for the rest of her life."

Many colorful myths are related all over Africa as reasons for the operations. Though all the myths are still believed by the ethnic groups involved inn the rural areas, many of the reasons are contradictory, and none of them are compatible with biological facts.

Most Africans who practice these operations believe that excision is a custom decreed by the ancestors; therefore, it must be complied with. Most often, men refuse to marry girls who are not excised. Since marriage is still the only career for a woman in most of Africa and the Middle East, the operations continue. "No proper Kikuyu would dream of marrying a girl who has not been circumcised," stated Jomo Kenyatta, the revered leader of Kenya, in his book, Facing Mount Kenya, which was written in the 1930s and continued to be published, and is also sold in tourist shops in Nairobi.

As President of Kenya for life, Kenyatta had great influence on Africans well beyond the borders of Kenya, and his much quoted statement is responsible for the mutilation of many thousands of helpless little girls and untold suffering and deaths.

The successor of Kenyatta, President Arap Moi, categorically prohibited female genital mutilation operations in 1982. He also alerted the Health Services that no more operations may be done in hospitals, which shows that the Kenyan Health Services were involved in the mutilations. Unfortunately, there has been no follow-up, teaching or educating the people against the mutilations. As a result, they have gone underground.

Excision, by cutting out the most sensitive tissues of a woman's body, extinguishes sexual sensitivity, pleasure and response to touch. The elimination of female sexual pleasure is the reason most frequently given for the genital mutilations, which is to keep "moral behavior of women in society" and "to assure the faithfulness of women to their husbands" - who usually have several wives. In many ethnic groups, for instance in Mali and Francophone West Africa, the operation traditionally is performed just before marriage, as a puberty rite; it is claimed that a woman can be accepted into adult society and get married only after she is operated upon.

In the Sudan and the Middle East, and in Moslem societies, for instance in Somalia, it is said that a woman is incapable of controller her sexuality - hence she must be excised or infibulated or she will disgrace her family. Women who do not have their genitals mutilated are considered to be prostitutes.

Excision is also perceived as a way to increase fertility; and the wish of most women is to have as many children as possible, especially sons, on which their status in society depends. The biological facts about reproduction are unknown or ignored. It is widely believed, for instance, in Mali and Burkino Faso, and all over West Africa, that the clitoris connotes maleness, and the prepuce of the penis, femaleness. Hence, both have to be removed before a person can be accepted as an adult in his/her sex and society. It is also believed that a girl who is not operated on will run wild and disgrace her family. In Egypt, aesthetic reasons are sometimes cited for the operation, and this is occasionally said in other areas of Africa as well. It is said that women's external genitalia are ugly and must be removed to make her acceptable to a man.

Hypertrophy of the clitoris - by which is meant an unusual enlargement of the organ - is cited as reason for excision in Ethiopia and also in parts of Nigeria. The Catholic Church has sanctioned the genital mutilation of all female children of its converts on those grounds since the 17th Century when the Pope sent a medical mission to Ethiopia.

Health reasons are often cited, especially in urban areas where the traditional myths are forgotten. Cleanliness is the reason given also by middle class women in areas as far apart as Cairo and Bamako.

Also, in Sudan, genital mutilations are connected with cleanliness and is called "Tahur," which in Arabic means purity. A woman is considered dirty and polluted unless she is mutilation. The same is often said in Somalia.

Many of the reasons given by local populations are quite similar, though they have been arrived at quite independently, as no connection or communication exists between the population groups involved. Most of these myths are promoted by men, which once more documents the amazing world-wide similarity of male attitudes concerning female sexuality.

Obviously, all of the myths are designed to justify and continue the female genital mutilations, from which men derive power and control over women as a group. This is, of course, the real reason why these operations continue today, and why they are being rapidly introduced into the modern sector throughout the African continent with the collusion of Western men, and especially the male-dominated health system. Though the social rites and ceremonies are minimized or forgotten, the surgery continues: and a lot of money can be made from this.

The genital mutilations are now performed on much younger children especially in the towns, as it is feared by men that the girls will resist once they go to school. Even in areas where traditionally the operations were a coming-of-age custom, they are now done on very young children, sometimes a few years old, or even shortly after birth. The stated purpose of the operation - introduction to adult life - has disappeared. Nevertheless, the mutilations continue to be practiced even in families of government officials and political leaders where many of the men have been to European or Western universities. The reasons given by these men are "tradition" - yet the men have rejected all African traditions for their own Westernized personal lives.

The patriarchal family structure and ideology of male supremacy supported by religion provides the underpinning for genital mutilations both past and present. It is well recognized that religious beliefs are invariably cited to support the "necessity" for having the genitals of daughters excised and/or infibulated. The operations are practiced by animists - those who believe in ancestor worship - stating that "the ancestors decreed these operations and their wishes must be followed.

They are practiced by Moslems - indeed in the Sudan and also in West Africa the local sheiks and marabouts claim that excision or infibulation is a required or "preferable" Moslem rite. But Egyptian Moslem religious authorities at the recognized El Azhar University state there is no requirement for female genital mutilation in the Koran. Male circumcision, however, is an absolute command.

Excision and infibulation are practiced by Christians of all denominations. As stated earlier, the Papacy of the Roman Catholic Church has officially supported the genital mutilations every since a medical mission was sent from Rome to Ethiopia in the 18th Century which declared that genital mutilations are "necessary."

The followers of the Ethiopian Christian Church and the Copts in Egypt (more than seven million adherents) have always mutilated the genitals of their female children. Indeed, all religions (with the exception of the Scottish Protestant Church in Kenya in the 1920s) have actively supported or tolerated the mutilation of girls to make the pliable subjects of the dominant patriarchal community that vests all rights in the males. There is no doubt that genital mutilation does permanent life-long physical and psychological damage to women. The full impact of the often terrible psychological consequences have never been systematically investigated though it is known that numerous young women commit suicide, as, for instance, reported in Burkina Faso.

Patriarchal religions - there are no others in Africa/The Middle East - provide the intellectual basis for men to keep their power and privileges in society. Who is going to question "the holy religious beliefs" expressed by men? Certainly not women - the vast majority in Africa and the Middle East are still illiterate (in some countries up to 90%). And men from Western countries, especially those concerned with development, have been warned by the militant male politicians to keep hands off their "culture," which in Africa and the Middle East sanctions polygamy, wife beating (the diameter of the stick if specified in some countries), the bride price (selling of young girls into marriage by their fathers), unilateral divorce, child marriage and female genital mutilations.

Over the centuries and due to their isolation, women have come to believe that the mutilation of their genitals are "necessary." Indeed, many women think that they are done all over the world. Thus, they are accepted as "natural." Some African women even now cannot believe that the operations are not done in other parts of the world.

The wholesale support of cultural traditions by anthropologists without critical evaluations of the often terrible damage done to the most vulnerable members of each community - children, especially female children and women - is completely irresponsible. There is hardly a major development program in Africa by the U.S. Agency for International Development - especially in health - that does not consult an anthropologist. I have frequently run into those "development advisers" who impose their ethnocentric views on multimillion dollar health programs in Africa. As a result, the terrible health damage done to girls and women by traditional practices is ignored because it is the "culture." I testified repeatedly before Congressional Committees - especially those concerned with appropriations for Foreign Aid to attract attention to the health needs of women, especially in Africa, about the modernization of female genital mutilations which are a violation of human rights.

I stated in my Congressional testimony, "My research in Africa shows that genital mutilations are increasingly performed in the modern sector in Africa, including hospitals, often on small babies, stripped of all traditional rites. This is a gross abuse of modern medicine. As Editor of WIN NEWS, I must advise this Committee that frequently health equipment, tools and training contributed by the U.S. and other Western donors is used to mutilate female children. Speaking for American women and tax-payers, I strenuously object to the use of U.S. monies and contributions to carry out sexual castrations - that is, clitoridectomies and infibulations - on non-consenting children in Africa and the Middle East."

The desire of modernization and especially all kinds of imported equipment and tools, especially by men, provides a unique opportunity for men to teach their African brothers that these genital mutilations are not acceptable. Only men can reach their African counterparts on this subject - especially since sexuality is involved, to teach them the biological facts in a persuasive way and from their own experience. Unfortunately, no one has ever really tried to reach African men who make all the decisions in each family about the truth regarding female genital mutilations. Men also have been left out where family planning programs are concerned - which are all imported by Development and Population experts. As a result, family planning in Africa has and is failing.

It is up to the male development and health advisers and all those who have contact with African men - for instance, the way many students from Africa at Western Universities - to talk to them about excision and infibulation and to explain to them why these genital mutilations are unacceptable. But unfortunately, such educational programs have not been tried.

African women have now started to organize to fight against these terrible genital mutilations in a systematic way. The Inter-African Committee was created in 1984, five years after the ground-breaking seminar, organized by WHO, on the "Traditional Practices Affecting the Health of Women and Children" held in Khartoum, Sudan.

As a temporary adviser to WHO - the sponsor of the meeting - I provided an overview of female child genital mutilations around the globe. This meeting opened up the international discussion on female genital mutilations, which had been a taboo subject until then. That was in 1979. The seminar attracted world-wide attention with delegations and observers from the health departments of nine African and Middle Eastern countries, as well as many Sudanese physicians and health officials. Unfortunately, limited action followed this seminar.

Four recommendations were unanimously voted by the delegates at the end of this fateful meeting:

Adoption of clear national policies for the abolishment of female circumcision;

Establishment of national commissions to coordinate and follow up the activities of other bodies involved including, where appropriate, the enactment of legislation prohibiting female circumcision;

Intensification of general education of the public, including health education at all levels, with special emphasis on the dangers and the undesirability of female circumcision;

Intensification of education programs for traditional birth attendants, midwives, healers and other practitioners of traditional medicine, to demonstrate the harmful effects of female circumcision, with a view to enlisting their support along with general efforts to abolish this practice.

The Inter-African Committee, formed in 1984 at an international meeting and headed by Berhane Ras-Work, by now has affiliated National Committees in 14 African countries and has offices in Addis Ababa (at the ECA - Economics Commission of Africa) and Geneva. They held several overflow meetings at the 1985 U.N. Decade Conference for Women in Nairobi and have published an "Action Plan" that provides an excellent set of guidelines for the National Committees to follow - who have held meetings in many African countries.

A ground-breaking International Seminar on "Strategies to Bring About Change" was held in June 1988, in Mogadishu, to draw world attention to the Somalian Campaign to Eradicate Infibulation - which was started two years ago.

The SWDO (Somali Women's Democratic Organization), jointly with ADIoS (The Italian Association for Women in Development) has organized a national campaign, fully supported by the Somalian government, to eradicate these damaging traditional practices. Indeed, every department of the Somalian government is involved in this national initiative led by the outspoken president of the SWDO, Muraio Garad Ahmed, who wields considerable political power.

AIDos, led by Daniela Colombo and with the assistance of the Italian government, has worked jointly with the SWDO in Somalia to develop viable strategies and extensive teaching aids for all different kinds of programs addressed to different sectors of the population.

The secrecy surrounding infibulation has only recently begun to be lifted in Somalia. It took considerable courage for the SWDO to take up this issue. Thanks to the perseverance of its leadership, it now has become a national campaign supported not only by the health ministry, but also by all other ministries, especially education. The campaign to eradicate female child genital mutilation is going on in all the schools; it is discussed on the radio and TV. Indeed, no occasion is missed to create awareness among the population about the damage done by infibulation. All families are urged to stop having their daughters "done."

This international seminar had been preceded by a national meeting which had developed a program of action for the joint SWDO-AIDoS Information Campaign. At the international seminar in Mogadishu, many influential national and international leaders gave speeches at the opening and closing sessions in the great hall of the Parliament. The speakers included a representative of the President of Somalia, the Minister of Health, The SWDO President, the Italian Ambassador, representatives of UNICEF, WHO, AIDoS and others.

Delegates from several African countries, including Egypt, Sudan, The Gambia and Nigeria presented outlines about the successful campaigns and strategies to eradicate female child genital mutilations in their countries. Egypt, with a program sponsored by the Cairo Family Planning Association, led by Aziza Kamel, has the most extensive experience in conducting a multitude of successful grassroots initiatives. From London, Stella Efua Graham, a native of Ghana and President of FORWARD (the Forward), outlined her educational work among African immigrants to the U.K. A doctor from Indonesia discussed how female circumcision in Indonesia had now been changed into a purely symbolic rite. Berhane Ras Work, the president of the Inter-African Committee (IAC) on "Traditional Practices Affecting the Health of Women and Children" founded in 1984, talked about its work all over Africa.

Women's International Network (WIN) was represented at the seminar by Fran P. Hosken, who spoke about the actions against female child genital mutilations all over the world, and about the Universal Childbirth Picture Books, with additions to prevent excision and infibulation that WIN has developed and introduced all over Africa with much success. The books are currently being translated.

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