By Frances A. Althaus
Female circumcision, the partial or total cutting away of the external female genitalia, has been practiced for centuries in parts of Africa, generally as one element of a rite of passage preparing young girls for womanhood and marriage. Often performed without anesthetic under septic conditions by lay practitioners with little or no knowledge of human anatomy or medicine, female circumcision can cause death or permanent health problems as well as severe pain. Despite these grave risks, its practitioners look on it as an integral part of their cultural and ethnic identity, and some perceive it as a religious obligation.
Opponents of female genital cutting, however, emphasize that the practice is detrimental to women's health and well-being. Some consider female circumcision a ritualized form of child abuse and violence against women, a violation of human rights.
The debate over female circumcision is relatively recent. The practice was rarely spoken of in Africa and little known in the West until the second half of this century. In the 1950s and 1960s, however, African activists and medical practitioners brought the health consequences of female circumcision to the attention of international organizations such as the United Nations and the World Health Organization (WHO). Still, it was not until 1979 that any formal policy statement was made: A seminar organized by WHO in Khartoum to address traditional practices affecting the health of women and children issued recommendations that governments work to eliminate the practice.1
During the following decade, the widespread silence surrounding female circumcision was broken. After African women's organizations met in Dakar, Senegal, in 1984 to discuss female circumcision and other detrimental cultural practices, the Inter African Committee Against Harmful Traditional Practices (IAC) was formed. With national committees in more than 20 countries, the IAC has been important in bringing the harmful effects of female circumcision to the attention of African governments. In addition, other African women's networks and organizations that had focused primarily on such issues as reproductive health, women's rights and legal justice became involved in working against the practice. Such groups as Mandalaeo Ya Wanawake in Kenya, NOW in Nigeria and New Woman in Egypt now include the elimination of female circumcision among their goals.
In part because these groups brought fresh perspectives to the issue, the emphasis in discussions of female circumcision shifted to encompass women's human and reproductive rights as well as their health. International consensus statements and treaties such as the Convention to Eliminate All Forms of Discrimination Against Women, the Convention on the Rights of the Child and the African Charter on the Rights and Welfare of the Child began to include language applicable to female circumcision. These documents, however, did not directly mention the practice, focusing instead on broad categories such as detrimental practices, violence and rights violations.2
With shifts in emphasis came new language: Although activists and clinicians continued to refer to female circumcision when working directly with women in the community, policy statements and other documents began to use the term "female genital mutilation." That term was used in the first international document to specifically address the practice, the Programme of Action adopted by the International Conference on Population and Development in Cairo in 1994.3 The Program refers to female genital mutilation as a "basic rights violation" and urges governments to "prohibit and urgently stop the practice...wherever it exists."
In the Platform of the Fourth World Conference on Women, held in Beijing in 1995, female genital mutilation was cited as both a threat to women's reproductive health and a violation of their human rights.4 In addition to making general recommendations, the Platform specifically called on governments to "enact and enforce legislation against the perpetrators of practices and acts of violence against women, such as female genital mutilation...." Notably, the drive to include language specifically condemning female genital mutilation in the Platform was led by Africans.
Against this background of activity and changing emphasis, the plight of Fauziya Kassindja, a 17-year-old woman from Togo, focused public attention in the United States on female circumcision. More important, her case was instrumental in redefining the practice as gender-based violence that could be grounds for the granting of political asylum.5 Kassindja, who fled her homeland in October 1994 to avoid an arranged marriage and the genital cutting that would be part of the marriage rites, was placed in a detention center after arriving in the United States under a false passport and asking for asylum. She was released a year and a half later and granted asylum after intensive media coverage of her situation.
Female circumcision is currently practiced in at least 28 countries stretching across the center of Africa north of the equator; it is not found in southern Africa or in the Arabic-speaking nations of North Africa, with the exception of Egypt.6 Female circumcision occurs among Muslims, Christians, animists and one Jewish sect, although no religion requires it.*
The availability of reliable figures on the prevalence of female circumcision has increased greatly in recent years: National data have now been collected in the Demographic and Health Survey (DHS) program for six countries--the Central African Republic, Côte d'Ivoire, Egypt, Eritrea, Mali and Sudan. In these countries, from 43% to 97% of reproductive-age women have been circumcised.7 Within countries, prevalence may vary across ethnic groups; in Mali, for example, where the overall proportion of women who have undergone circumcision is 94%, only 17% of women of Tamachek ethnicity have been circumcised.
Estimates for other countries are generally based on local surveys or anecdotal information. The estimated proportion of women who have undergone circumcision in these countries ranges from 5% in Uganda and the Congo (formerly Zaire) to 98% in Djibouti and Somalia.8 Both because of wide variations in prevalence across social and demographic subgroups and because of data limitations, these figures should be interpreted with caution.
Types of Circumcision
Although circumcision may be performed during infancy, during adolescence or even during a woman's first pregnancy, the procedure is usually carried out on girls between ages four and 12. In the countries for which DHS data are available, the median age at excision ranges from less than two months in Eritrea to about six years in Mali and almost 10 years in Egypt. The operation is generally performed by a traditional birth attendant or an exciseuse, an elder village woman.
There are three basic types of genital excision, although practices vary widely. In the first type, clitoridectomy, part or all of the clitoris is amputated, while in the second (often referred to as excision), both the clitoris and the labia minora are removed. Infibulation, the third type, is the most severe: After excision of the clitoris and the labia minora, the labia majora are cut or scraped away to create raw surfaces, which are held in contact until they heal, either by stitching the edges of the wound or by tying the legs together. As the wounds heal, scar tissue joins the labia and covers the urethra and most of the vaginal orifice, leaving an opening that may be as small as a matchstick for the passage of urine and menstrual blood.9
The overall proportion of women who have undergone each type of circumcision is not known, although clitoridectomy appears to be by far the most common procedure. It is estimated that about 15% of all circumcised women have been infibulated, although an estimated 80-90% of all circumcisions in Djibouti, Somalia and the Sudan are of this type.10
Consequences of Excision
In the conditions under which female circumcision is generally performed in Africa, even the less extensive types of genital cutting can lead to potentially fatal complications, such as hemorrhage, infection and shock. The inability to pass urine because of pain, swelling and inflammation following the operation may lead to urinary tract infection. A woman may suffer from abscesses and pain from damaged nerve endings long after the initial wound has healed.
Infibulation is particularly likely to cause long-term health problems. Because the urethral opening is covered, repeated urinary tract infections are common, and stones may form in the urethra and bladder because of obstruction and infection. If the opening is very small, menstrual flow may be blocked, leading to reproductive tract infections and lowered fertility or sterility. One early study estimated that 20-25% of cases of sterility in northern Sudan can be linked to infibulation.11
Without deinfibulation before childbirth, obstructed labor may occur, causing life-threatening complications for both mother and infant. Because birthrates are high in many countries where infibulation is practiced, a woman's infibulation scar may be cut and resewn many times during her reproductive years.
In addition, the amputation of the clitoris and other sensitive tissue reduces a woman's ability to experience sexual pleasure. For infibulated women, the consummation of marriage is likely to be painful because of the small vaginal opening and the lack of elasticity in the scar tissue that forms it. Tearing and bleeding may occur, or the infibulation scar may have to be cut open to allow penetration.
Infibulation may make intercourse unsatisfying for men as well as women: In a study of 300 polygynous Sudanese men, each of whom had one wife who had been infibulated and one or more who had not, 266 expressed a definite sexual preference for the uninfibulated wife; in addition, 60 said they had married a second, uninfibulated wife because of the penetration difficulties they experienced with their first wife, whose scarred vaginal opening became progressively more inelastic after each birth.12 Under such conditions, marital dissolution may occur, especially if a woman's fertility is affected. In Sudan, for example, one study found that infibulated women are almost twice as likely as other women to have lower fertility and more than twice as likely to be divorced.13 Thus, a practice that is justified as making girls marriageable and safeguarding their fertility may actually increase the risk of marital dissolution and subfertility.
Given the medical complications and related consequences of female circumcision, why does the practice continue? First, it is unclear how frequently such problems occur, for few data exist and those that are available come from small studies or are based on self-reports. Second, in societies in which few women remain uncircumcised, problems arising from female circumcision are likely to be seen as a normal part of a woman's life and may not even be associated with circumcision. The most important reasons, however, probably lie in the social and economic conditions of women's lives.
Female circumcision is an integral part of the societies that practice it, where patriarchal authority and control of female sexuality and fertility are givens. In communities where a person's place in society is determined by lineage traced through fathers, female circumcision reduces the uncertainty surrounding paternity by discouraging or preventing women's sexual activity outside of marriage. Although the societies that practice circumcision vary in many ways, most girls receive little education and are valued primarily for their future role as sources of labor and producers of children. In some communities, the prospective husband's family pays a brideprice to the family of the bride, giving his family the right to her labor and her children; she herself has no right to or control over either.
A girl's virginity may be considered essential to her family's ability to arrange her marriage and receive a brideprice, as well as to family honor. In Somalia, for example, a prospective husband's family may have the right to inspect the bride's body prior to marriage, and mothers regularly check their infibulated daughters to ensure that they are still "closed."14 In this context, parents see both infibulation and early marriage as means of ensuring that their daughter remains "pure" and thus worthy of the brideprice.
In many cultures, considerable social pressure is brought to bear on families who resist conforming to the tradition of female circumcision. In Man, a town in the interior of Côte d'Ivoire, a Yacouba girl who has not been circumcised is not considered marriageable.15 Among the Samburu of Kenya, who consider uncircumcised girls unclean, promiscuous and immature, girls are generally circumcised at age 14 or 15, usually just before they are married. A girl with a younger brother may undergo circumcision if she remains unmarried by her late teens, since custom dictates that a boy with an uncircumcised older sister may not be initiated into the warrior class.16
Girls' desires to conform to peer norms may make them eager to undergo circumcision, since those who remain uncut may be teased and looked down on by their age mates. In addition, the ritual cutting is often embedded in ceremonies in which the girls are feted and showered with presents and their families are honored. A girl's wishes, in any case, are often irrelevant; it is her family--often the father or elder female relatives--who decide whether she will undergo circumcision. According to one Yacouba father, "[My daughter] has no choice. I decide. Her viewpoint is not important."17
Indeed, girls have very little choice. Given their age and their lack of education and resources, they are dependent on their parents, and later on their husband, for the basic necessities of life. Those who resist may be cut by force. If they remain uncircumcised and their families are therefore unable to arrange a marriage, they may be cast out without any means of subsistence.
Because of their lack of choice and the powerful influence of tradition, many girls accept circumcision as a necessary, and even natural, part of life, and adopt the rationales given for its existence. Of the five countries for which DHS data are available on women's opinions toward excision, the Central African Republic is the only one in which the majority favor discontinuation.18 A variety of justifications are given by DHS respondents who favor continuation of the practice, including preservation of virginity before marriage, fidelity after marriage, enhancement of the husband's sexual pleasure, enhancement of fertility, prevention of infant and child mortality, cleanliness and religious requirements, but tradition is by far the most commonly mentioned reason.
As these data show, women themselves are involved in perpetuating the practice of female genital cutting. Data on the attitudes of men have been collected only in Eritrea and Sudan. DHS data for Eritrea show that men are slightly more likely than women to favor discontinuation, and that men who believe the practice should be stopped are about twice as likely as their female counterparts to cite medical complications and lack of sexual satisfaction as reasons.19 In Sudan, a 1981 study found that men are somewhat more likely than women to believe female genital cutting should continue, but are less than half as likely as women to prefer infibulation.20
Working for Change
Efforts to eliminate female circumcision have often been unsuccessful because opponents of the practice ignored its social and economic context. In some cases, external intervention has strengthened the resolve of communities to continue their genital cutting rituals as a way of resisting what they perceive as cultural imperialism.
During the era of colonial rule in Africa, some governments attempted to ban female circumcision and met with resistance. In Sudan, when a law banning infibulation was about to be proclaimed in 1946, many parents rushed to midwives to have their daughters infibulated in case it should become impossible later on. When some midwives were arrested for performing circumcision, anticolonial protests broke out. The British colonial government, fearing a massive nationalist revolt such as those that had occurred in Egypt and Kenya, eventually let the law go uunenforced.21
More recently, calls to action by Western feminists and human rights activists have provoked similar negative reactions. African women have perceived many of these efforts as condescending and derogatory toward their culture. In the words of one infibulated Somali woman, "If Somali women change, it will be a change done by us, among us. When they order us to stop, tell us what we must do, it is offensive to the black person or the Muslim person who believes in circumcision. To advise is good, but not to order."22
In many Western publications dealing with female circumcision, one anthropologist observes, "African women are...depicted as aberrant, while intact Western women have their sexuality affirmed as the norm."23 Yet, as Nahid Toubia points out, Western women also subject themselves to medically unnecessary, hazardous procedures, such as cosmetic surgery and the insertion of breast implants, to increase their sexual desirability.24
The strong reactions against depictions of cultures practicing female circumcision as savage, violent and abusive of women and children have led to new ways of approaching the issue. Some international organizations working against the practice are supporting local activist groups with funding, training and technical expertise rather than choosing direct involvement. Numerous projects have been mounted to eliminate female circumcision, although none have included rigorous evaluations to determine their success. The following approaches are typical:
*Community education. A nationwide study conducted in 1985-1986 by the National Association of Nigerian Nurses and Midwives found that female circumcision was practiced in all states and that in five of the then 11 states at least 90% of the women had been cut. In response to this information, the organization designed an eradication campaign with support from Population Action International and the Program for Appropriate Technology in Health. The project trained health workers to teach individuals about the harmful effects of female circumcision and to work through religious organizations, women's organizations and social clubs to mobilize communities against the practice.25
*Alternative rituals. The organization Maendeleo Ya Wanawake carried out a pilot project in the Meru district of Kenya in 1996 to develop an alternative initiation ritual. Some 25 mother-daughter pairs participated in a six-day training session that included information on the consequences of female circumcision and how to defend the decision not to be cut. The session culminated in a coming-of-age celebration planned by the community, excluding circumcision but including gifts and special T-shirts for the initiates, skits, and "books of wisdom" prepared by the parents of each girl.26
*Drama. In Burkina Faso, the director of a local theater group developed a play, based on the experience of his niece, on the consequences of female circumcision; the play is aimed particularly at men. A grant from the Research Action and Information Network for Bodily Integrity of Women (RAINBO) enabled him to videotape the play and show it throughout the region.27
Prospects for the Future
The available data provide little evidence that the practice of female circumcision will decline substantially in the near future. The Central African Republic, where prevalence is moderate, is the only country in which steady decline seems to be occurring. Young women in Côte d'Ivoire, Egypt, Eritrea and Mali appear to be no less likely than older women to have undergone circumcision. In Sudan, the sole country for which longitudinal comparisons can be made, prevalence appears to have declined slightly, from 96% to 89%, between the 1978-1979 Sudan Fertility Survey and the 1989-1990 Sudan DHS.28 Nevertheless, the DHS data do not indicate any differences between younger and older women.
Despite the overall lack of change in the percentages of girls who undergo circumcision, changes in attitudes and practices seem to be occurring in some countries. In Eritrea, for example, women and men younger than 25 are much more likely than those in their 40s to believe that the tradition should be discontinued. In Sudan, where the great majority of women have traditionally been infibulated, there appears to be a small shift toward clitoridectomy.29
Given the lack of enforcement of most laws against female circumcision, it is unclear whether a purely legal approach is effective in itself. While legislation may be enforceable in countries where only a small minority adhere to the practice, that is unlikely to be the case when the majority follow the tradition. As Toubia points out, "Clear policy declarations by government and professional bodies are essential to send a strong message of disapproval, but if the majority of the society is still convinced that female genital mutilation serves the common good, legal sanctions that incriminate practitioners and families may be counterproductive."30 In such countries, she suggests, public information campaigns and counseling of families about the effects of the practice on children may be more useful.
Substantial change is likely to occur only with improvements in the status of women in society. According to Rogaia Abusharaf, "To get married and have children, which on the surface fulfills gender expectations and the reproductive potential of females, is, in reality, a survival strategy in a society plagued with poverty, disease, and illiteracy....The socioeconomic dependency of women on men affects their response to female circumcision."31
This view is born out by the DHS data: In most countries, women with higher levels of education and those who have income of their own are less likely than other women to have been circumcised and are also less likely to have had their daughters circumcised. As Toubia comments, "this one violation of women's rights cannot [be abolished] without placing it firmly within the context of efforts to address the social and economic injustice women face the world over. If women are to be considered as equal and responsible members of society, no aspect of their physical, psychological or sexual integrity can be compromised."32
1. World Health Organization (WHO), Khartoum Seminar on Traditional Practices Affecting the Health of Women and Children, Khartoum, Sudan, 1979.
2. Organization of African Unity, African Charter on the Rights and Welfare of the Child, 1990, Article 24(3).
3. United Nations (UN), Report of the International Conference on Population and Development, New York, 1994.
4. UN, Report of the Fourth World Conference on Women, New York, 1995.
5. C.W. Dugger, "A Refugee's Body Is Intact but Her Family Is Torn," New York Times, Sept. 11, 1996, pp. A1, B6-B7.
6. N. Toubia, Female Genital Mutilation: A Call for Global Action, RAINBO, New York, 1995.
7. R. Ndamobissi, G. Mboup and E.O. Nguélébé, Enquête Demographique et de Santé, République Centrafricaine, 1994-95, Direction des Statistiques Démographiques et Sociales, Bangui, Central African Republic, and Macro International, Calverton, Md., USA, 1995; N'Cho Sombo et al., Enquéte Demographique et de Santé, Côte d'Ivoire, 1994, Institut National de la Statistique, Abidjan, Côte d'Ivoire and Macro International, Calverton, Md., USA, 1995; F. El-Zanaty et al., Egypt Demographic and Health Survey 1995, National Population Council, Cairo, and Macro International, Calverton, Md., USA, 1996; Eritrea Demographic and Health Survey, National Statistics Office, Asmara, Eritrea, and Macro International, Calverton, Md., USA, 1997; S. Coulibaly et al., Enquête Demographique et de Santé, Mali, 1995-1996, Direction Nationale de la Statistique et de l'Informatique, Bamako, Mali, and Macro International, Calverton, Md., USA, 1996; and Sudan Demographic and Health Survey, 1989/1990, Ministry of Economic and National Planning, Khartoum, Sudan, and Macro International, Calverton, Md., USA, 1991.
8. N. Toubia, 1995, op. cit. (see reference 6).
9. WHO, Female Genital Mutilation: Report of a WHO Technical Working Group, Geneva, 1996.
11. A.Z. Mustafa, "Female Circumcision and Infibulation in the Sudan," Journal of Obstetrics and Gynaecology of the British Commonwealth, 73:302-306, 1966.
12. A.A. Shandall, "Circumcision and Infibulation of Females," Sudan Medical Journal, 5:178-212, 1967.
13. D. Balk, "Marriage and Fertility in Northeast Africa: What Role Does Female 'Circumcision' Play?" unpublished manuscript, 1997.
14. A. Warsame, "Social and Cultural Implications of Infibulation in Somalia," in Female Circumcision: Strategies to Bring About Change, Proceedings of the International Seminar on Female Circumcision, Italian Association for Women in Development, Rome, 1989; and V.L. Barnes and J. Boddy, Aman: The Story of a Somali Girl, Knopf, Toronto, 1994.
15. C.W. Dugger, "African Ritual Pain: Genital Cutting," New York Times, Oct. 5, 1996, pp. A1 & A6.
16. J.C. McKinley, Jr., "At a Ceremony in Kenya, a Brother and Sister Painfully Enter Adulthood," New York Times, Oct. 5, 1996, p. A6.
17. C.W. Dugger, 1996, op. cit. (see reference 15).
18. R. Ndamobissi, G. Mboup and E.O. Nguélébé, 1995, op. cit. (see reference 7).
19. Eritrea Demographic and Health Survey, 1997, op. cit. (see reference 7).
20. E.-H. Kheir, S. Kumar and A.R. Cross, "Female Circumcision: Attitudes and Practices in Sudan," in Proceedings of the Demographic and Health Surveys World Conference, Washington, D.C., 1991, Vol. 3, Columbia, Md., USA, 1991, pp. 1697-1717; and A. El Dareer, Woman, Why Do You Weep? Zed Books, London, 1982.
21. J. Boddy, personal communication, May 26, 1997.
22. V.L. Barnes and J. Boddy, 1994, op. cit. (see reference 14).
23. J. Boddy, "Violence Embodied? Female Circumcision, Gender Politics, and Cultural Aesthetics," in R. Dobash and R. Dobash, eds., Rethinking Violence Against Women, Sage, Thousand Oaks, Calif. (in press).
24. Na. Toubia, 1995, op. cit. (see reference 6).
25. S. Babalola and C. Adebajo, "Evaluation Report of Female Circumcision Eradication Project in Nigeria," paper presented at the annual meeting of the American Public Health Association, New York, Nov. 18, 1996.
26. S. Rich and S. Joyce, "Eradicating Female Genital Mutilation: Lessons for Donors," occasional paper, Wallace Global Fund, Washington, D.C., 1997.
28. E.-H. Kheir, S. Kumar and A.R. Cross, 1991, op. cit. (see reference 20).
29. I bid.
30. N. Toubia, 1995, op. cit. (see reference 6), p. 45.
31. R.M. Abusharaf, "Rethinking Feminist Discourses on Female Genital Mutilation: The Case of Sudan," Canadian Woman Studies, 15:52-54, 1995.
32. N. Toubia, 1995, op. cit. (see reference 6).
*Although female circumcision is often thought to be associated with Islam, it predated Islam in Africa. Neither the Koran, the primary source for Islamic law, nor the "hadith," collections of the sayings of the Prophet Mohammed, include a direct call for the practice (see: reference 6). According to these oral histories, when Mohammed was asked his opinion on female circumcision, he told his followers "to circumcise, but not to destroy (the clitoris), for not destroying would be better for the man and would make the woman's face glow." Islamic clerics are divided, however, with some actively supporting the practice and others opposing it.
Frances A. Althaus is senior editor of International Family Planning Perspectives. The author is grateful to Nahid Toubia and Rogaia Abusharaf for their generous help in preparation of the report and to Dara Carr, Jacqueline E. Darroch, Jeannie Rosoff, Renee Samara and Susheela Singh for helpful comments on an earlier version.
© copyright 1997, The Alan Guttmacher Institute.