The old Kurdish midwife's hands trembled alongside a bowl that she positions to catch dripping blood. She picked up a razor blade and sliced through a corner of paper, mimicking the ritual cut she has performed at least 500 times, on young girls' genitals.

"In the name of God, the most compassionate and merciful," Naksheen Moustafa said. "That's it! It's simple. I have never had a problem with this procedure in all the time I have done it."

But in a small home on the outskirts of the same village in northern Iraq, Jiana Ali Mohammed sat on the floor, her wide eyes staring into the middle distance. Jiana, now 17, underwent female genital mutilation twice as a seven-year-old; once by a midwife in the morning, and the second time later that day by her grandmother, who thought the job had not been done properly. Her clitoris and labia were sliced away, a procedure far more invasive than the symbolic nip described by Moustafa. Jiana bled for days and lost movement for a while in her lower limbs.

She is developmentally delayed and socially backward. Her mother, Nazeka Shemen, blames her daughter's woes on the trauma of that day.

All four of her daughters before Jiana also underwent genital mutilation, but she said she would never put a new daughter through the ordeal.

"I have come to accept that it was wrong," said Shemen. "I would not do this to another child and I regret doing what we have done. Everyone has done it in Rania, including me. It is not a practice that has been questioned until recently."

There was a widespread feeling among the Kurdish women watching Moustafa's demonstration that the midwife was deliberately underestimating the cruelty of her cut, perhaps because of wariness about increasing scrutiny from the outside world.

For 20 years, the village elder has been the woman that parents take their daughters to in Rania village, in Iraq's north, to undergo female genital mutilation, arguably in greater numbers proportionally than anywhere else in the Middle East. Around 90% of adult women in at least eight villages in the Sulaymaniyah district alone are believed to been subjected to the practice.

Moustafa, 68, learned her cottage craft from another old woman, who, until she died, had been one of the last practitioners of this highly contentious tradition in Iraqi Kurdistan.

Judging by the knowledge bestowed, neither Moustafa nor her predecessors could be deemed to be midwives in the true sense of the word. Clinical care appears to have been universally absent in the practice. So too, until very recently, was antiseptic or even basic surgical dressings. Instead, ash is often rubbed into the wound.

Family 'honour'

The absence of modern medicine has not deterred many of the families in Rania and a swath of Iraq's remote Kurdish north from continuing with a tradition that has been disavowed in much of Arab Iraq and by Islamic clerics across the region.

Even now, after more than two decades of public awareness programmes in often impoverished villages, parents are still sending their girls in large numbers, believing it to be the fulfilment of a Qur'an instruction, which will cause the girls no harm and will instead help purify the family home.

Unlike elsewhere in Iraq, the practice of female genital mutilation became entrenched in the Kurdish north as a convention passed on through the ages.

Recent research by Human Rights Watch showed that there are at least four factors driving this: a link to Kurdish identity, a religious imperative, social pressure, and an attempt to control a woman's sexuality.

The mix of motivations has combined to give the custom a hold that prevails in the face of rulings from leading religious figures, a move by Kurdish law-makers to outlaw it, and the scorn of conservative societies outside the north who look down on the Kurds' ways.

Recent studies, including an Iraqi human rights ministry survey conducted last year, show that up to 23% of Iraqi Kurdish girls under 13 have undergone female genital mutilation. However, the report also reveals the figure is sharply higher among girls aged 14 to 18 (45%), suggesting an apparent recent shift in attitudes.

Slowly, mothers in Rania and, in some cases, the sheikhs who offer religious authority for the practice, are beginning to reassess their views. A key reason for this is the palpable harm that has been done to girls like Jiana.

There is evidence in Rania that comprehensive slicing of a girl's genitals has been commonplace.

Four women spoken to by the Guardian say they bled for many days after their procedures, which took place before any of the girls reached sexual maturity.

Two of them say they continue to suffer from infections. All the women said they were told that the procedures had upheld their family honour.

Others in the village say they have had no problem with the tradition. The Otthman family's six daughters have all been attended to by Moustafa. "She came here with a ball of cotton and a razor," said the girls' mother, Basra Sayed.

"I believe that this is prescribed by Islamic tradition and should be done to both boys and girls," she said. "The difference in our society has been that for the boys we get a doctor to do it, and for the girls we get a midwife.

"None of my daughters had any complications, but I have heard that there were girls who bled a lot and had to go to hospital. My girls, however, were cut during the morning and were fine by the afternoon."

Sayed insists that her daughters were not subjected to the procedure that removes their labia, or clitoris. "It was just like the old lady said, she was very professional and quick.

"Two of my daughters are now married," she added. "And they both fully enjoy their sexual lives."

Sayed's words reflect the fact that inroads appear to have been made into at least one taboo – discussion about the impact of the procedure on a woman's sexual health and enjoyment.

Human Rights Watch last year interviewed 31 victims, many of whom described traumatic experiences that have left lasting consequences. A report prepared by Asuda, the women's rights group, also last year found sexual enjoyment in many victims was greatly diminished.

Religious debate

The best hope of eradicating female genital mutilation as a convention in the Kurdish north appears to rest with Muslim clerics. On that front, the prognosis appears mixed.

"We have seen some clerics prepared to accept that this is not sanctioned by religion," said the director of Asuda's Suleimaneya office, Khanim Latif. "But there are others who still say strongly that it is."

Throughout Rania, there is a sense that more people than ever before are looking disapprovingly at the practice and, by extension, their society.

People here seem ready to accept change, but only if it is spelt out wholeheartedly by the clerics they have listened to for generations.

"We want the clerics to say, stop doing this," said Jian's mother. "We are waiting for this and the time is right to do it."

The ageing midwife up the road also seemed willing to accept change.

"If a sheikh said today to stop this, I would stop it today," she said, dropping the razor blade and cotton wool into her bowl.

Her voice trailing away, she added: "This has never hurt anyone, but if it could … I don't want to be the one responsible."