Professional Documents
Culture Documents
Female genital mutilation is the term now generally accepted for the traditional practices that entail removal
of part or all of, or injury to the external genitalia of girls and women. It does not include genital surgery
performed for medically prescribed reasons.
The term was first used by feminists, women’s health advocates and human rights activists and was
subsequently adopted by the Inter African Committee at a meeting in Addis Ababa, Ethiopia (1990). Since
then, it has also been adopted by the United Nations and is increasingly being used by the public. Prior to
its adoption, the practices were referred to as “female circumcision” a term still in common use.
The terminology used to describe the different forms of female genital mutilation varies widely
among the population groups where they are practiced and among researchers, health personnel, health
advocates and others. Removal of the prepuce has been called “true circumcision”, in that it is equivalent to
male circumcision. Clitoridectomy is sometimes referred to as “mild circumcision” and is also known as
“Sunna circumcision” by some Muslim communities. However, the Koran does not recommend any form of
female genital mutilation and it is suggested that, in order to prevent any misunderstanding that there is
such a link, the term “Sunna” should be discouraged. Infibulations may be termed “severe circumcision”
and is also known as “Pharaonic circumcision” in Sudan and “Sudanese circumcision” in Egypt. A modified
form of infibulation has been called “intermediate circumcision”.
Attempts to classify female genital mutilation also vary considerably, since the different types of
procedure have never been clearly defined. The classifications in current use generally distinguish three
main types:
Excision of the prepuce and clitoris
Excision of the prepuce, clitoris and labia minora
Infibulation
Furthermore, it is a reflection of discrimination against women and girls, as such should be condemned by
all and sundry.
Female genital mutilation (FGM), often referred to as 'female circumcision', comprises all procedures
involving partial or total removal of the external female genitalia or other injury to the female genital organs
whether for cultural, religious or other non-therapeutic reasons. There are different types of female genital
mutilation known to be practised today. They include:
• Type I - excision of the prepuce, with or without excision of part or all of the clitoris;
• Type II - excision of the clitoris with partial or total excision of the labia minora;
• Type III - excision of part or all of the external genitalia and stitching/narrowing of the vaginal
opening (infibulation);
• Type IV - pricking, piercing or incising of the clitoris and/or labia; stretching of the clitoris and/or
labia; cauterization by burning of the clitoris and surrounding tissue;
• scraping of tissue surrounding the vaginal orifice (angurya cuts) or cutting of the vagina (gishiri
cuts);
• introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of
tightening or narrowing it; and any other procedure that falls under the definition given above.
The most common type of female genital mutilation is excision of the clitoris and the labia minora,
accounting for up to 80% of all cases; the most extreme form is infibulation, which constitutes about 15%
of all procedures.
The immediate and long-term health consequences of female genital mutilation vary according to the type
and severity of the procedure performed.
Immediate complications include severe pain, shock, haemorrhage, urine retention, ulceration of the genital
region and injury to adjacent tissue. Haemorrhage and infection can cause death.
More recently, concern has arisen about possible transmission of the human immunodeficiency virus (HIV)
due to the use of one instrument in multiple operations, but this has not been the subject of detailed
research.
Long-term consequences include cysts and abscesses, keloid scar formation, damage to the urethra
resulting in urinary incontinence, dyspareunia (painful sexual intercourse) and sexual dysfunction and
difficulties with childbirth.
Psychosexual and psychological health: Genital mutilation may leave a lasting mark on the life and mind of
the woman who has undergone it. In the longer term, women may suffer feelings of incompleteness,
anxiety and depression.
In cultures where it is an accepted norm, female genital mutilation is practiced by followers of all religious
beliefs as well as animists and non believers. FGM is usually performed by a traditional practitioner with
crude instruments and without anaesthetic. Among the more affluent in society it may be performed in a
health care facility by qualified health personnel. WHO is opposed to medicalization of all the types of female
genital mutilation.
The age at which female genital mutilation is performed varies from area to area. It is performed on infants
a few days old, female children and adolescents and, occasionally, on mature women.
• psychosexual reasons: reduction or elimination of the sensitive tissue of the outer genitalia,
particularly the clitoris, in order to attenuate sexual desire in the female, maintain chastity and
virginity before marriage and fidelity during marriage, and increase male sexual pleasure;
• sociological reasons: identification with the cultural heritage, initiation of girls into womanhood, social
integration and the maintenance of social cohesion;
• hygiene and aesthetic reasons: the external female genitalia are considered dirty and unsightly and
are to be removed to promote hygiene and provide aesthetic appeal;
• myths: enhancement of fertility and promotion of child survival;
• religious reasons: Some Muslim communities, however, practise FGM in the belief that it is demanded
by the Islamic faith. The practice, however, predates Islam.
Most of the girls and women who have undergone genital mutilation live in 28 African countries, although
some live in Asia and the Middle East. They are also increasingly found in Europe, Australia, Canada and the
USA, primarily among immigrants from these countries.
Today, the number of girls and women who have been undergone female genital mutilation is estimated at
between 100 and 140 million. It is estimated that each year, a further 2 million girls are at risk of
undergoing FGM.
CURRENT WHO ACTIVITIES RELATED TO FGM
A joint WHO/UNICEF/UNFPA policy statement on FGM and a Regional Plan to Accelerate the Elimination of
FGM were published to promote policy development and action at the global, regional, and national level.
Several countries where FGM is a traditional practice are now developing national plans of action based on
the FGM prevention strategy proposed by WHO.
A major objective of WHO's work on FGM is to generate knowledge, test interventions to promote the
elimination of FGM. Research protocols on FGM have been developed with a network of collaborating
research institutions as well as biomedical and social science researchers with linkages to appropriate
communities. WHO has reviewed programming approaches for the prevention of FGM in countries and has
organized training for community workers to strengthen their effectiveness in promoting prevention of FGM
at the grassroots level.
WHO has developed training materials for integrating the prevention of FGM into nursing, midwifery and
medical curricula as well as for in-service training of health workers. Evidence based training workshops, to
raise the awareness of health workers and to solicit their active involvement as advocates against FGM,
have also been developed for nurses and midwives in the African and Eastern Mediterranean region.
Female Genital Mutilation (FGM) is a cultural practice that started in Africa approximately 2000 years ago. It
is primarily a cultural practice, not a religious practice. But some religions do include FGM as part of their
practices. This practice is so well ingrained into these cultures, it defines members of these cultures. In
order to eliminate the practice one must eliminate the cultural belief that a girl will not become a women
without this procedure.
Female Genital Mutilation is the term used for removal of all or just part of the external parts of the female
genitalia. There are three varieties to this procedure.
1. Sunna Circumcision - consists of the removal of the prepuce(retractable fold of skin, or hood) and
/or the tip of the clitoris. Sunna in Arabic means "tradition".
2. Clitoridectomy - consists of the removal of the entire clitoris (prepuce and glands) and the removal
of the adjacent labia.
In Africa 85% of FGM cases consist of Clitoridectomy and 15% of cases consist of Infibulation. In some
cases only the hood is removed.
What is the age, the procedure used and the side effects?
The age the procedure is carried out varies from just after birth to some time during the first pregnancy, but
most cases occur between the ages of four and eight. Most times this procedure is done with out the care of
medically trained people, due to poverty and lack of medical facilities. The use of anesthesia is rare. The girl
is held down by older women to prevent the girl from moving around. The instruments used by the mid-wife
will vary and could include any of the following items; broken glass, a tin lid, razor blades, knives, scissors
or any other sharp object. These items usually are not sterilized before or after usage. Once the genital area
for removal is gone, the child is stitched up and her legs are bound for up to 40 days.
This procedure can cause various side effects on the girls which can include death. Some of the results of
this procedure are serious infections, HIV, abscesses and small benign tumors, hemorrhages, shock, clitoral
cysts. The long term effects may also include kidney stones, sterility, sexual dysfunction, depression,
various urinary tract infections, various gynecological and obstetric problems.
In order to have sexual intercourse the women have to be opened up in some fashion and in some cases
cutting is necessary. After child birth some women are re-infibulated to make them (tight) for their
husbands.
In an FGM society, a girl can not be considered to be an adult until she has undergone this procedure. As
well as in most cultures a women can not marry with out FGM. The type of procedure used will vary with
certain conditions and these conditions could include the females ethic group, the country they live in, rural
or urban areas, as well as their socioeconomic provenance.
FGM is a culture identity practice. The fact that the procedure helps to define who is the group, is obvious in
cultures that carry out this procedure as an initiation into womanhood. Most FGM societies feel that unless a
girl has this procedure done she is not a woman as well as removal of these practices would lead to the
demise of their culture.
FGM societies have many claims of why this procedure should be done and these are as follows:
1. In most FGM societies one important belief is that this procedure will reduce a women's desire for
sex and in doing so will reduce the chance of sex outside the marriage. This is vital to this society
as her honor for the family is depended on her not to be opened up prior to marriage.
2. Some view the clitoris and the labia as male parts on a female body, thus removal of these parts
enhances the femininity of the girl.
3. It is also believed that unless a female has undergone this procedure she is unclean and will not
be allowed to handle food or water.
4. Some groups believe that if the clitoris touches a man's penis the man will die. As well as the
belief that if a baby's head touches the clitoris that the baby will die or the breast milk will be
poisonous.
5. The belief that an unmutilated female can not conceive, therefore the female should be militated in
order to become fertile.
6. Bad genital odors can only be eliminated by removing the clitoris and labia minora.
7. Prevents vaginal cancer.
8. An unmodified clitoris can lead to masturbation or lesbianism.
9. Prevents nervousness from developing in girls and women.
10. Prevents the face from turning yellow.
11. Makes a women's face more beautiful.
12. Older men may not be able to match their wives sex drive.
13. Intact clitoris will generate sexual arousal and in women if repressed can cause nervousness.
FGM does predate Islam, but most Muslims do not practice this. FGM was also practice by Falasha (Ethiopian
Jews). The remaining FGM society's follow traditional Animist religions. To see a list of groups click here.
In countries where Muslim's practices FGM, they can justify it, in the words of the Prophet Mohammed, in
these two controversial sayings that are found in the Sunnah (words and actions of Mohammed)
A discussion was recorded between Mohammed and Um Habibah (or Um'Alyyah), a women
performed infibulation on slaves. She said that she would continue the procedure "unless it is
forbidden and you order me to stop doing it". He replied (according to one translation) "Yes it is
allowed. Come closer so I can teach you: if you cut, do not over do it, because it brings more
radiance to the face and it is more pleasant for the husband."
Mohammed is recorded as speaking of the Sunna circumcision to Ansar's wives
saying: "Cutting slightly with out exaggeration, because it is more pleasant for your husbands."
These passages are regarded to have little credibility or authenticity with in the Muslim religion and is
contradiction in the Qur'an:
God apparently created the clitoris for the sole purpose of generating pleasure. It has no
other purpose. There is no instructions in the Qur'an or in the writings of the Prophet
Mohammed which require that the clitoris be surgically modified. Thus God must approve of its
presence. And also, it should not be removed or reduced in size or function.
the Qur'an promotes the concept of a wife being given pleasure by her husband during
sexual intercourse. Mutilated genitalia reduces or eliminates a women's pleasure during the
act.
There is an estimated 135 million girls and women that have gone through this procedure with an additional
2 million a year at risk. This procedure is practiced in Africa (28 countries), Middle East, parts of Asia as well
as in North America, Latin America, and as well as in Europe. It is now believed that the practice originated
in Africa and is a cultural practice. Follow this link to see some indicators supporting this conclusion.
Amnesty International now has taken up the fight to do away with this practice that mutilates millions of
girls each year. Today FGM is seen as a human rights issue and is recognized at an international level. FGM
was in the universal framework for protection of human rights that was tabled in the 1958 united Nation
agenda. It was during the UN Decade for Women (1975-1985) that a UN Working Group on Traditional
Practices Affecting the Health of Women and Children was created. This group helped to develop and aided
to the development of the 1994 Plan of Action for the Elimination of Harmful Traditional Practices Affecting
the Health of women and Children. the World Health Organization, the United Nations Children's' Fund and
the Untied Nations Population Fund, unveiled a plan in April 1997 that would bring about a major decline in
FGM within 10 years and the complete eradication of the practice within three generations.
Nahld Toubia, MD, a physician from Sudan and assistant clinical professor in CSPH's center for Population
and Family Health states: "Female circumcision is the physical marking of the marriage ability of women,
because it symbolizes social control of their sexual pleasure-- clitoridectomy--and their reproduction--
infibulation," Toubia also believes that female circumcision raises numerous human right issues, including
reproductive rights, the protection from violence, women's rights and especially children’s rights since most
circumcisions take place on girls who are four to ten years of age. Even though there is no theological basis
for the practice of FGM, it will be hard to eradicate, until we have a better understanding of the cultural
beliefs.
Professor Stephen Isaacs, J.D, who specializes in human rights issues states "Human rights transcend
cultural relativism by definition," and goes on to also state "But the cultural-religious argument has to be
taken into consideration for implementation of policy."
But with this Toubia maintains that the goal in ending FGM must never be compromised. "No ethical defense
can be made for preserving a cultural practice that damages women's health and interferes with their
sexuality," "It is only a matter of time before all forms of female circumcision in children will be made illegal
in Western countries and, eventually, in Africa." Toubia states.
Definition
The World Health Organization (1997) defined Female Genital Mutilation (FGM) as "all procedures involving partial
or total removal of the female external genitalia or other injury to the female genital organs whether for cultural
or other non-therapeutic reasons."
The United Nations identifies FGM as a form of human rights abuse on the female child and supports the
eradication of this practice in countries where it is prevalent.
Origins of Practice
The act of Female Genital Mutilation predates both Christianity and Islam and does not pertain to any specific
religion. The practice of infibulation is thought to have arisen out of ancient Egypt. It is also suggested that FGM
was associated with patriarchal societies in which men needed assurance of family blood lines. Clitoridectomy, a
less extreme form of FGM, was known to be used in Western medicine as late as the 1950's as a treatment for
perceived "female psychiatric illnesses."
These are complex, arising from a belief system based on cultural and social tradition and impinge on the
woman's social acceptance and marriageability within her community. While some people believe FGM to be part
of religious requirements, this is in fact not the case.
Prevalence of Practice
The WHO (2000) estimates that as many as 100 and 140 million women and girls are affected world wide. This
extrapolates to approximately 2 million girls per year at risk of being circumcised. Regions where various
extremes of FGM are practiced include Africa, Asia, South America and the Middle East.
Use of Terminology
The term Female Genital Mutilation may cause offence to some who practice or have experienced the procedure.
Its use in consultation may have the potential to be counterproductive to forming an effective professional
relationship with the client and hence detrimental to the provision of her ongoing care for what is a sensitive
issue. Accepted forms of description are traditional female surgery or cutting or female circumcision.
The different types of FGM are classified by the extent of the surgery:
• Type 1: Excision of the prepuce, with or without excision of part or all of the clitoris.
• Type 11: Excision of the clitoris with part or total excision of the labia minora
• Type 111: Excision of part or all of the external genitalia and stitching/ narrowing of the vaginal opening
(infundibulation)
• Type 1V: Unclassified, but includes: pricking, piercing or incising the clitoris and/ or labia, stretching of
the clitoris and/ or labia, cauterization by burning of the clitoris and surrounding tissue, scraping of the
tissue surrounding the vaginal orifice or cutting of the vagina, the introduction of corrosive substances or
herbs into the vagina to initiate tightening, bleeding or narrowing of the vagina, as well as any other
procedure which falls under the WHO definition of FGM.
Health Consequences of FGM
• severe pain
• shock
• haemorrhage
• trauma
• infection
• urinary retention
• damage to adjacent tissues.
• Death can result from infection or haemorrhage.
• dysuria
• implantation cysts
• dyspareunia
• recurrent UTI's and vaginal infections
• dysmennorrhoea
• PID / infertility
• surgical reversal of scar tissue in order to achieve intercourse.
FGM may have long term effects on the psychosexual and psychological health of those who have undergone the
procedure.
In more recent times concern has been expressed about the possible transmission of human immunodeficiency
virus (HIV) due to the use of one instrument for multiple FGM procedures, but as yet is not confirmed by research
(WHO, 2000).
Management
• Women from regions known to practice the procedure should be asked whether they have undergone
female circumcision in their first antenatal appointment at the hospital.
• Staff should be aware that women affected by the practice may also be experiencing a range of
psychosocial issues that have arisen from their experience of FGM and/or migration and resettlement.
• The aim needs to be holistic care that is culturally sensitive and non judgemental (RANZCOG, 1997).
• The gender provider wishes of the woman should be taken into account in regard to care and referral.
If the woman has been affected by FGM an appointment should be made for her to see a Medical Obstetric FGM
Liaison Officer, who will discuss with the woman her options regarding de-infibulation during pregnancy or labour
(refer to flowcharts).
Clinical Management:
For details including deinfibulation and re-suturing diagrams and instructions go to FARREP Web site: Practice
Guidelines.
• Click on Clinical Management.
• Following de-infibulation over-sewing of the raw margins of the anterior incision is required to prevent re-
infibulation with poor approximation of wound edges.
• Any extension of the anterior incision above the urethra may be repaired at that time.
• A routine repair of a medio-lateral episiotomy or perineal tear is also frequently required post labour.
Referrals
• Referrals to appropriate healthcare providers should be offered to women, including referral to the FARREP
worker.
• The RWH offers the de-infibulation procedure to both pregnant and non-pregnant consumers of our care.
• Contact may be made via FARREP, Women's Health Information Centre (WHIC) or the Outpatients
Department.
De-infibulation - Gynaecology
• For women seeking de-infibulation at the RWH appointments should be made for them with one of
the Medical Gynaecology FGM Liaison Officers.
Legal Issues
• Staff are expected to be aware of specific legislation in the State of Victoria and elsewhere in Australia
which makes it a criminal offence to perform FGM.
• Further information is available from FARRUP and the RWH Legal Counsel.
• Support/advice can be gained from Family and Reproductive Rights (FARREP) worker, extension 2211 or a
FGM Liaison Officer as necessary.
• FGM Liaison Officer details for Medical, Nursing and Allied health staff.
• Flowcharts
Antenatal, Birth Suite, Postnatal, Gynaecology
Supportive Material
• RWH: Female Genital Mutilation (FGM) Resource Manual for Health Professionals,
o services provided at Royal Women's Hospital
o algorithms for antenatal clinics and labour ward
o practice guidelines
• Female Genital Mutilation. Information for Australian Health Professionals. The Royal Australian College of
Obstetricians and Gynaecologists, 1997
• The Royal Australian and New Zealand College of Obstetricians and Gynaecologists www.ranzcog.edu.au/
• Mama and Nunu (Mother and Baby), Pregnancy Care for African Women: An Information Manual for
Service Providers, Women's Health West, 60 Droop Street Footscray, 3011. Tel. 9689 9588.
• Women's Health Information Centre, Royal Women's Hospital, Tel. (03) 9344 2007.
• Family and Reproductive Rights Education Program Worker (FARREP), Royal Women's Hospital, Tel. (03)
9344 2211.