FGM Type IV and Other Forms of Female Genital Alterations

oP the C s of ebate The d

The Debates of the Community of Practice on FGM FGM Type IV and other forms of female genital alterations

September 2019

W W W . C O P F G M . O R G e CoP of th ates of e deb rms Th er fo d oth s V an ation ype I alter GM T nital F le ge fema FGM Type IV and other forms of female genital alterations I. Introduction

The World Health Organization defines FGM as “procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons”. The organization classifies it in 4 main types and considers all types of FGM to be a violation of the human rights of girls and women. In this note, we will focus on FGM type IV. (WHO, 2018).

FGM type IV encompasses a range of procedures done to the female genitals that do not fall under the first 3 types (partial or total removal of the clitoral gland, excision of the labia minora or majora, and infibulation). The definition for type IV was changed in the new typology, published in 2007, to be less detailed than the previous one (1995). Practices such as the introduction of corrosive substances and herbs into the vagina, as well as labia stretching were removed.

2008 typology, FGM IV: All other harmful procedures to the female genitalia for non-medical purposes, for example, pricking, piercing, incising, scraping and cauterization.

Previous (1995) typology, FGM IV: Unclassified: 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 broad definition of female genital mutilation.

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Type IV FGM include a large variety of practices and are often less known than other types as they are largely under-researched and under- reported. Thus, practitioners may find it difficult to identify and understand the different forms and complexities around type IV FGM procedures (Afruca, 2016).

This thematic note presents some forms of FGM type IV as well other forms of female genital alterations that are not currently included in this category by WHO, and/or that are not included in the official prevalence statistics. We also discuss some controversies around these practices.

The goal of the note is to encourage a discussion and knowledge-sharing on practices that are or could be potentially harmful and yet are less known to the wider public and sometimes not officially considered to be “FGM”. It is our ambition that the discussion will allow us to improve the knowledge around these types as well as advocacy and prevention of less known yet potentially harmful female genital alterations.

II.Pricking

What, Where, Why?

Pricking of the clitoris gland or surrounding tissue, is a procedure in which the skin is pricked with a sharp object and blood may be let, but no tissue is removed and no stitching performed. Pricking is practiced in several communities around the world, as a traditional type of FGM or as a replacement of more extensive cutting. It is classified by the WHO as FGM type IV. (WHO, 2008).

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In some communities of Southeast Asia, for example, pricking is considered as part of socialization of girls. Some see it as an Islamic practice and it is generally perceived by communities as harmless (Wahlberg A. et al, 2017).

Pricking has been reported to have gained support in several communities who traditionally perform other types of FGM. In Somaliland, pricking is considered ‘Sunna’, and is seen as a less severe form of FGM, compared to other practices such as “Pharaonic”, infibulation (type III). (Lunde & Sagbakken, 2014). Nevertheless, evidence shows that “Sunna” can also refer to other types of FGM without infibulation, such as type I and II.

In Guinea, where a variety of forms of FGM are practiced, research suggests that some families are also starting to opt for a type IV FGM involving a “slight symbolic incision on the genitals”. (UNHCR, 2001).

Although the practice of pricking is increasingly discussed, there is a lack of empirical data on pricking and on its possible consequences for the girls and women submitted to it. (Wahlberg A. et al, 2017).

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Controversies around pricking

When reviewing the FGM typology, the WHO considered the debate on Pricking and its harmfulness. In their Interagency statement they explained the choice to keep pricking in the FGM typology:

“Discussion on whether pricking should be included in the typology and defined as a type of female genital mutilation has been extensive. Some researchers consider that it should be removed from the typology, both because it is difficult to prove if there are no anatomical changes, and because it is considered significantly less harmful than other forms.” (WHO, 2008)

The WHO noted that pricking is also considered by some as a possible “harm- reduction strategy”, as a replacement of more invasive procedures. Nevertheless, other stakeholders have argued that pricking should remain in the FGM typology “either to enable documentation of changes from more severe procedures, or to ensure that it cannot be used as a "cover up" for more extensive procedures, as there are strong indications that pricking described as a replacement often involves a change in terminology rather than a change in the actual practice of cutting.“ The WHO further stated that “studies have shown that when women who claim to have undergone "pricking" have been examined medically, they have been found to have undergone a wide variety of practices, ranging from Type I to Type III. Hence the term can be used to legitimize or cover up more invasive procedures.“ For these reasons, the WHO decided to keep pricking in the Type IV.

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A controversial piece, by an anonymous author, published in the Economist in 2016 argued in favor of accepting a “symbolic nick”, done by a medical professional. The author(s) argued that a new approach to FGM prevention was needed and that the “symbolic nick” was preferable to more invasive practices such as type I, II or III. (anonymous, 2016) Another piece, by two American gynecologists, sparked new life to this debate in 2018. The authors, Arora and Jacobs, also argued in favor of pricking as a “compromise solution”. According to them, pricking almost never has a lasting effect on morphology or function, if performed properly. Thus, permitting this less extensive procedure could allow families to uphold cultural and religious traditions while protecting girls from more dangerous forms of cutting and infibulation of the vulva. (Arora & Jacobs, 2018) .

Many experts agree that bringing about FGM abandonment in communities is difficult (even when they are aware of health consequences), because the practice is so deeply entrenched in cultural norms (Askew et al, 2016). However, zero tolerance advocates strongly oppose genital pricking as an acceptable solution and specialists argued that even a “small nick” can have important negative mental and health consequences on the girl - as there is no straightforward correlation between extent of the cut and consequence. In fact, the way the practice is performed, such as by holding girls down on the ground, can be more traumatic than the cut itself. (Richard, 2018)

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III. Genital piercing

What, Where, Why ?

Piercing can be defined as “an opening in any part of the body through which jewelry might be worn”. The most common forms of female genital piercing are of the clitoral hood, of which there are different types. The clitoral gland or the labia may also be pierced. In some cases, the labia minora or majora may be pierced once or more, and one or more rings may bridge the gap to give a ‘chastity ring’ (Kelly & Foster, 2012).

Female (as well as male) genital piercings is legally performed in piercing studios and tattoo parlors all over the world. In Europe and North America they became increasingly popular in the 21st century with celebrities speaking openly about them. There is historical evidence of genital piercings in women and men from various countries and ethnic groups. They seem to be increasingly popular in some African countries, such as Ghana (Ghanaweb, 2016).

Historically, outer labial rings have been used to prevent wives and slaves from having sexual intercourse. Today, however, most women (and men) who undergo genital piercing do so voluntarily for aesthetic and /or sexual reasons, and as markers of their individuality. There are numerous stories on the internet of women who explain why they wanted a genital piercing.

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Consequences of genital piercings

An exploratory study, done in clients of one piercing studio in the US in 2003, identified a positive relationship between “vertical clitoral hood piercing and desire, frequency of intercourse and arousal. There were no dramatic differences in orgasmic functioning.” (Millner et ał, 2004)

While some experts argue that genital piercings may increase the risk of infections or compromise the integrity of barrier contraception (Preslar and Borger, 2019), a US study found that few of the pierced participants (men and women) had problems with sexual transmitted infections and that the great majority were happy with their piercing. (Caliendo et al, 2005). Nevertheless, compared to piercing of the clitoral hood, piercing of the clitoral glans may involve more risks such as injury to the nerves and blood supply of the clitoral structures leading to future fibrosis and diminished function. (Moulton & Jernigan, 2017).

Controversies around (female) genital piercings

In UK a public debate broke out after it was announced in the media that the National Health Service would register genital piercings in women as “FGM type IV”. Several organizations and activists strongly opposed the idea that a genital piercing chosen by adult women could be compared to female genital mutilation imposed on infants and children. They argued that adult women should have the right to consent to alterations of their own body. (Kelly & Foster, 2012)

September 2019

W W W . C O P F G M . O R G CoP f the tes o deba of The rmsn ? er fiogio d oth rel s V anr of ation ype Iatte alter GM Ta m nital GF M, le ge F fema IV. Vaginal incisions, scraping, hymenotomies Different types of vaginal incisions, including hymenotomy (removal of the hymen), are performed in the world. They are considered FGM Type IV and involve incisions with or without removal of tissue.

IV.i Vaginal incisions and hymenotomies (Dangouria, Haabize, Angurya, Gishiri) in Niger and Nigeria

What, Where, Why? Hymenotomies are incisions done to the hymen. In some communities, they are practiced on girls for non-medical reasons. This practice is not to be confused with hymenotomies performed surgically as a treatment in women or girls presenting an imperforate hymen resulting in abdominal pain.

In Niger, the practice known as Dangouria (in hausa language) or Haabize (in zarma) involves two procedures: The removal of the hymen in newborn girls, usually within 10 days of birth, when a small part of the hymen is visible outside the vulva. It is generally carried out by traditional barbers, wanzam, or midwife, unguzoma, with a razor blade. The second procedure is performed on girls who marry before their bodies have fully matured, usually when they are between nine and 15 years old, and involves making an incision in the vaginal opening to facilitate sexual intercourse. (UNICEF, Ouedraogo, 2017)

A study of the links between angurya cuts and fistula, in Niger, showed that all cuts had been done not as a « passing of age ritual » (such as other types of FGM) but as a supposed « treatment » fo dyspareunia (painful intercourse), lack of interest in or unwillingness to engage in sexual intercourse, as well as female behavior that was deemed to be culturally inappropriate by the male spouse, parents, or in-law. There is a belief in Niger, that a girl can be born with a seed (gurya translates to cotton seed) within her genitals that can grow over time and can lead to sexual dysfunction.

The study showed that it was performed on women who were victims of child/forced marriage an d were struggling with non-consensual sex or physical/sexual abuse by their husbands. (Ouedraogo, 2017)

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W W W . C O P F G M . O R G e CoP of th f bates ms o he de r for T othe n ? and ltiigoinos pe IV fl treera M Ty rta lo a FG a gtetnei am amle FGMf,e

FGM is prevalent throughout Nigeria with practices ranging from infibulation, to excision and type IV cuts without removal of flesh. Type IV FGM includes Angurya and Gishiri cuts, which were included in the definition of the practice for some states in 2008 and then for the whole country in 2013, resulting in a higher prevalence rate compared to previous years. (DHS, 2013 and DHS, 2008) Similarly to the practice performed in Niger, Nigerian Angurya cuts, involve excision of the hymen (hymenectomy or scraping of the tissue surrounding the vaginal opening) when considered too thick. It is typically done on baby girls soon after birth and is thought to assist with easy penetration when a husband and wife consummate their marriage (based on the cultural expectation that a woman would not have sex before marriage). (Obianwu, 2019) In Nigeria it is most common among women in the Islamic community (54 percent), those in the Fulani and Hausa ethnic groups (87 percent each), and those living in the North West zone (84 percent). Women with no education (70 percent) and those in the lowest wealth quintile (76 percent) were most likely to have had angurya cuts. (DHS, 2013) Another type of FGM type IV performed in Nigeria and Niger, Gishiri cuts, are an incision to the anterior or posterior vaginal wall using either a razor blade or a pen knife. Five percent of women in Nigeria have undergone this procedure, mostly in the North West zone (DHS 2013). It is used as a « therapeutic » practice to treat a range of conditions including obstructed labour, infertility, amenorrhea (absence of menses), vulvar itching (Obianwu, 2019, Ouedraogou, 2017).

« Among the Hausa of northern Nigeria, there is a cultural belief in a gynecological condition called gishiri. gishiri. Gishiri is the Hausa word for « salt » and it refers to the common salt used in cooking, and to the chemical salts deposited at the bottoms of water jars as their contents evaporate. (…) The accumulation of « salt » in the vagina is thought to cause various ill-defined gynecological complaints. » (Ouedraogo, 2017, p. 367)

In Nigeria, the DHS also reports use of corrosive substances, an unclassified type of harmful female genital practice, which is most common among Catholic women and women in the Ijaw/Izon ethnic group. (DHS, 2013)

September 2019

W W W . C O P F G M . O R G e CoP of th ates of e deb rms Th er fo on ? d oth eligi s V an f r ation ype I ter oalter GM T mat nital F , a le ge FGM fema IV.ii Cutting in the vaginal opening to “remove warts” (southieute) in Senegal

What, Where, Why?

An exploratory study by Senegalese sociologist Fatou Kebe, currently looks at a practice involving cutting of the vaginal opening of women, justified by the “removal of warts” (Sothieute in Wolof). According to Kebe, this practice is common in the Wolof community of Senegal and happens when a newly married woman has difficulties having intercourse with her husband. Women are expected to be virgins before marriage.

Genital warts are caused by certain types of human papillomavirus (HPV), which are a sexual transmitted virus. They are thus highly unlikely in persons who have not had sexual relationships. The preliminary study of Kebe also indicates that there are no actual warts present in the women who undergo this practice. In fact, the intervention seems to have no medical justification. Instead, it is believed that women who are subjected to this practice suffer from vaginism or do not consent to the sexual intercourse. Hence, the author considers it to be a form of FGM. (GAMS, 2019).

This practice can be compared to the one in Nigeria, described above, as it is performed tofacilitate vaginal penetration. More extensive reserach would have to be conducted on theSenegalese practice in order to understand the prevalence, the underlying reasons and thepotential consequences for the women who undergo it.

The Wolof community in Senegal is generally said to be an FGM non-practicing community. According to the Demographic Health study of Senegal, the prevalence is less than 1% for girls having a Wolof mother. (DHS, 2018) Hence, the recognition of this practice as a type of FGM would likely have a consequence on the general FGM prevalence of Senegal as well as the national policies against FGM.

September 2019

W W W . C O P F G M . O R G CoP f the tes o deba of The rmsn ? er fiogio d oth rel s V anr of ation ype Iatte alter GM Ta m nital GF M, le ge F fema IV.iii Incisions to introduce herbs, South Africa

What, Where, Why? Different types of harmful female genital alterations have been reported in South Africa. Studies from the 1990s have documented genital incisions among female sex workers in KwaZulu-Natal. These women reported the practice of ukugcaba: making small incisions in the genital area close to the labia with a razor blade, after which herbal substances were rubbed into the wounds, allegedly to attract men and keep them sexually satisfied. (Scorgie et al, 2010)

Moreover, other types of harmful vaginal alterations have been recorded in the country,including the ritual breaking of the hymen with a finger or animal horn, a tiny cut above the clitoris (Lobedu) and labia majora elongation.

It should be noted that WHO does not report South Africa as country in which FGM is practiced, except for migrant communities (Kitui, 2012).

V. Cauterization

What, Where, Why?

Cauterization is defined here as the destruction of tissue by burning it with a hot iron. This has been described as a remedy for several health problems, including bleeding, abscesses, sores, ulcers, and wounds, or for "counter-irritation". The term "cauterization" was retained in the WHO description of FGM type IV, but the specifications were removed to make the description more general, as there are little data on this practice. (WHO, 2008)

September 2019

W W W . C O P F G M . O R G e CoP of th ates of e deb rms Th er fo on ? d oth eligi s V an f r ation ype I ter oalter GM T mat nital F , a le ge FGM fema Other types of female genital alterations

In this section we describe other types of alterations done to the female genitals for non medical reasons which are not (currently) included in the WHO classification: Labia elongation, stretching or pulling Vaginal drying Aesthetical genital surgeries Clitoris massaging

VI. Labia elongation

What, Where, Why?

Labia minora are the thin lips or folds of skin on either side of the vulva. They show a widevariation in size from woman to woman, so there is no ‘normal’ labial length. Nevertheless, there are cultural differences in terms of aesthetical and sexual preferences for small or longer labia minora.

The practice of labia elongation is practiced in several parts of East and Southern Africa, including Uganda, Rwanda, Zambia and Mozambique.

The Baganda, an ethnic group living in Uganda, practice labial elongation as a tribal female initiation rite and the practice is always taught to young girls who are near puberty, between 9 and 16 years, and completed by menarche. The final size of the labia is at least one to one and a half inches in length.

September 2019

W W W . C O P F G M . O R G e CoP of th ates of e deb rms Th er fo on ? d oth eligi s V an f r ation ype I ter oalter GM T mat nital F , a le ge FGMfema In Zambia the action of pulling is known as kudonza, tidonza, or ukukuna and the elongated labia, with a final length from 1.5 to 2 inches, are called malepe or imishimo. Migrant Zimbabwean women living in South Africa, participating in a study by Perez et al. (2015) explained that these terms were only used in intimate spaces. The practice was taught to women by premarital counsellors or peers and was aimed at enhancing their male partner’s sexual pleasure. Tools were used to facilitate the pulling and girls organized in groups to meet in secret placed and perform mutual pulling. Womentestified of a variety of other genital modifications such as introducing substances into the vagina; washing with cold water and salt or wiping with a cotton/paper with lemon water, all of which to “control fluids” and tighten/contract the vagina, as well as scarifications and tattoos of the genitalia (Perez, et al. 2015)

In some parts of Mozambique, labia elongation is also associated with other genital practices such as vaginal tightening using various mildly astringent substances from herbs. This is practiced on a regular basis, together with labial elongation, by up to 65% of women (Audet et al, 2017).A cross-sectional study conducted in Tete province showed that 98% of the over 900 women participating had practiced labia elongation at some point and that few of them (4,5%) had experienced minor harms as a consequences, including irritation or pain, itching, inflammation, and dyspareunia (Hull et al. 2011, quoted in Perez et al, 2015).

The reasons behind labial elongation seems to be complex. The practice is meant to increase the pleasure of sexual intercourse for males and for females. Nevertheless, labia elongation isalso carried out for a number of other reasons: peer pressure; fear of not being marriageable and desirable to males if not practiced; fear of being stigmatized if not complying with elongated labia; beautifying routine; to help with problems which may arise during childbirth; sexual gratification of men insofar that it heightens sexual pleasures for men and for some women. (WHO, 2008, Afruca, 2016, Perez et al. 2015)

In many regions the practice seems to be slowly dying out as the socioeconomic profile of the region changes. This may or may not be a response to the introduction of Western ideas of female sexuality. (Thomas, 2018)

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Controversies around labial elongation

Surveys show that men and women alike seem to have a favorable attitude towards continuing this practice. Some authors argue that labial elongation does not fit the technical or traditional definition of female genital mutilation (FGM) because it is not associated with excision or incision of the female external genitalia, is aimed at increasing their size rather than lessening it, and aims to increase female sexual pleasure rather than restrict it (Thomas, 2018). A study of the practice in Rwanda also showed that women regard it as a positive force in their lives (Koster & Price, 2008). Moreover, the reproductive health risks of labia minora elongation are considered minor, limited to itching and irritation at the time of active stretching. (Mandal, 2018) Thus, instead of the negatively connoted FGM some authors argue that the term ‘female genital modification’ should be applied to this practice.

In fact, the WHO removed labial elongation from the definition of type IV in the 2008typology. However, in their report the organization argued that labial stretching might still be defined as a form of female genital mutilation because it is a social convention resulting insocial pressure on young girls to modify their genitalia, and because it creates permanentgenital changes. (WHO, 2008) An example of the strong social pressure surrounding the practice is demonstrated in the study by Martinez Perez et al. where Zambian women recalled psychosocial stress around the practice and the fear of not succeeding to achieve the desired length of labia:

“As girls, they worried they would not succeed in achieving malepe. They were fearful that their future husbands could send them back to their families arguing that they were not suitable for marriage. Many women, when girls, had restlessly anticipated the moment in which they could be checked before marriage.”

September 2019 W W W . C O P F G M . O R G e CoP of th ates of e deb rms Th er fo on ? d oth eligi s V an f r ation ype I ter oalter GM T mat nital F , a le ge FGMfema VII. Vaginal drying and tightening

What, Where, Why?

Intra-vaginal drying and tightening are commonly practiced in some parts of southern Africa.The practice has been a topic of discussion among scholars since the 1950s. Common intra-vaginal practices include the insertion of herbs and other agents to tighten the vagina precoitally as well as soap and water to clean the vagina. In communities where they are practiced, these practices are seen as fundamental to the construction of female identity, eroticism and the experience of pleasure. Women themselves have described vaginal drying and tightening as empowering, increasing perceived vaginal cleanliness and sexual pleasure for both her and her partner. (Audet et al, 2017) Nevertheless, vaginal drying and tightening may be associated with the alteration of the vaginal flora and vaginal lesions resulting in irritation and inflammation and making women more vulnerable to sexually transmitted infections, HIV, and bacterial vaginosis (Bagnol & Mariano, 2008, Audet et al, 2017)

VIII. Aesthetical genital surgeries and procedures

Aesthetical, or cosmetical, genital surgeries and procedures include a big variety of practicesdone for aesthetical or sexual reasons, including labioplasty (surgeries of the inner labia), labia majora filling or reduction, genital bleaching, G- spot injections, hymenoplasty (reconstruction of the hymen), laser vaginal rejuvenation, clitoral hood reductions, and others.

Contrarily to communities practicing labial elongation, the prevalent social norm in Europe and other Western societies is rather smaller vulvas with less protruding labia. Hence, some European and American women undergo aesthetical genital surgeries to reduce the size of their labia, sometimes as much as getting pre-pubescent- appearing labia. These types of aesthetical genital surgeries are sometimes known as “designer vaginas” (Mandal , 2018,Thomas, 2018)

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W W W . C O P F G M . O R G e CoP of th ates of e deb rms Th er fo on ? d oth eligi s V an f r ation ype I ter oalter GM T mat nital F , a le ge FGM fema Genital cosmetic surgery are legally accepted in many countries. However, some have argued that these forms of plastic surgery can be compared to FGM in different ways as they are generally practised for non-medical reasons, may have negative health consequences and that women undergo them because of social pressure brought on by the image of the “ideal vulva” or the obligation to be a virgin before marriage (in the case of hymen repairs).

VIV. Clitoral massaging

Evidence collected during a study done by the Population Council suggest that some communities in Imo State, Nigeria, perform "pressing" or "massaging” of the vulva/clitoris. This is performed as a transition from type I or type II cutting in FGM practicing communities, which is typically done in the first weeks or months after birth.

In families that decide to not have girls undergo a cut, the clitoris or external genitalia is instead pressed or massaged while bathing the baby girl, typically with warm water or Vaseline. The “massage” is done for the same reasons as cutting e.g. decrease sensitivity to reduce sexual urge and prevent promiscuity/extra marital or pre-marital sex and for aesthetics (prevent clitoris/labia minora from growing and protruding out of the labia majora).

The evidence suggests that some health workers in Imo state encourage this transition as a non-harmful alternative to cutting. Anti-FGM advocates (from both government and civil society) describe pressing/massaging as type IV FGM/C and strongly discourage the practice. However, some obstetricians andgynecologists have challenged this and state the “clitoral massage” is benign, has no physical effect and could not be classified as FGM. (Obianwu, 2019)

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VV. Conclusion

As seen in this note a variety of genital alterations are performed in different settings and for different reasons. Some are covered by the WHO typology as type IV but others are not.

The list in this document is not exhaustive.

We have seen that many types if genital alterations are under- reaserached. A number of questions remain unanswered, such as :

Why is FGM Type IV less known and less researched? Why are some practices not covered in the official WHO typology although they are practiced for non-medical reasons and harmful ? How can NGOs, researchers and policy-makers improve knowledge and prevention of these types of genital alterations permanently affecting women's bodies? Which are the potential obstacles, and the opportunities, to we raise awareness of female genital alterations/FGM in communities which are not generally considered "FGM praticing communities" ? Which types of female genital alterations acceptable and what proof do we have that they are not harmful?

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What do you think ? 1. Do you have information about un(der)documented types of female genital alterations, practiced in communities where you live/work?

2. What can be done to raise awareness on and prevent type IV FGM and other types of harmful genital alterations?

3. What do you think of the position of the international community on different types of genital alterations and type IV FGM? Should other practices be covered by the typology?

4. In your opinion and experience, are all types of genital alterations harmful to women and to be considered FGM? Can some types of genital alterations have positive effects for women who undergo them?

September 2019

W W W . C O P F G M . O R G CoP de la ébats Les d REFERENCES & RESSOURCES

1. Afruca, 2016, Type 4 FGM - Focus: Labia elongation https://www.trixonline.co.uk/website/news/pdf/policy_briefing_No-211.pdf

2. Agence Nationale de la Statistique et de la Démographie (ANSD) Sénégal, et ICF, 2018, Sénégal : Enquête Démographique et de Santé Continue 2017, Rockville, Maryland, USA: INSD et ICF.

3. Anonymous author, 2016, Female genital mutilation - An agonising choice, The Econimist: https://www.economist.com/leaders/2016/06/18/an-agonising-choice?frsc=dg%7Ca

4. Arora K. S. & Jacobs A. J., 2018, Female genital alterations: A compromise solution: http://belmont.bme.umich.edu/wp-content/uploads/sites/377/2018/02/2-Female-genital- alteration-a-compromise-solution.pdf

5. Askew I. et al, 2016, A repeat call for complete abandonment of FGM: https://jme.bmj.com/content/42/9/619)

6. Audet, C.,M. et al, 2017, Understanding intra-vaginal and labia minora elongation practices among women heads-of-households in Zambézia Province, Mozambique: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5460297/

7. Bagnol B. & Mariano E.,2008, Vaginal practices: eroticism and implications for women's health and condom use in Mozambique: https://www.ncbi.nlm.nih.gov/pubmed/18649196

8. Caliendo, C. et al, 2005, Self-reported characteristics of women and men with intimate body piercings. https://www.ncbi.nlm.nih.gov/pubmed/15713179

9. Community of Practice on FGM, 2019, "The Removal of the Southieuntes" in Senegal : An unknown type of FGM IV - Interview with Fatou Kebe: https://copfgm.org/2019/09/30/the-removal-of-the-sothieuntes-in-senegal-an-unknown- type-iv-of-mgf/

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10. Ghanaweb, 2016, Genital piercing increasing among Kumasi youth, Ghanaweb https://www.ghanaweb.com/GhanaHomePage/regional/Genital-piercing-increasing-among- Kumasi-youth-451271#

11. Kelly B. & Foster C., 2012, Should female genital cosmetic surgery and genital piercing be regarded ethically and legally as female genital mutilation? BJOG 2012;119:389–392 https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1471-0528.2011.03260.x

12. Kitui, B. 2012, Female genital mutilation in South Africa https://africlaw.com/2012/06/07/female-genital-mutilation-in-south-africa/

13. Koster M. & Price L, 2008, Rwandan female genital modification: Elongation of the Labia minora and the use of local botanical species, Culture, Health & Sexuality, Vol 10 (2) : https://www.tandfonline.com/doi/full/10.1080/13691050701775076? scroll=top&needAccess=true (21/09/2019)

14. Lunde, I. & Sagbakken, M., 2014, Female genital cutting in Hargeisa, Somaliland: is there a move towards less severe forms? Reproductive Health Matters, 22:43, 169- 177: https://www.tandfonline.com/doi/pdf/10.1016/S0968-8080(14)43759-5

15. Mandal, A., 2018, Health guide for young women regarding labiaplasty https://www.news- medical.net/news/20180313/Health-guide-for-young-women-regarding-labiaplasty.aspx

16. Millner V., S. et al, 2005, First glimpse of the functional benefits of clitoral hood piercings, American Journal of Obstetrics and Gynecology, Volume 193 (3) : https://www.deepdyve.com/lp/elsevier/first-glimpse-of-the-functional-benefits-of-clitoral- hood-piercings-W491dp0oxr

17. Moulton, L. J. and Jernigan, A, M. 2017, Management of Retained Genital Piercings: A Case Report and Review. Case Reports in Obstetrics and Gynecology: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5337326/

18. National Population Commission (NPC) [Nigeria] and ICF International, 2014, Nigeria Demographic and Health Survey 2013, Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF International.

19. National Population Commission (NPC) [Nigeria] and ICF Macro, 2009, Nigeria Demographic and Health Survey 2008. Abuja, Nigeria: National Population Commission and ICF Macro.

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W W W . C O P F G M . O R G CoP de la ébats Les d 20. Obianwu, O., 2019, personal communication

21. Ouedraogo, T., et al 2018, Gurya cutting and female genital fistulas in Niger: ten cases

22. Perez, G.,M. et al, 2015, Zambian Women in South Africa: Insights Into Health Experiences of Labia Elongation, The Journal of Sex Research, Volume 52, 2015 - Issue 8: https://www.tandfonline.com/doi/abs/10.1080/00224499.2014.1003027µ

23. Preslar, D. Borger J , 2019, Body piercing infections: https://www.ncbi.nlm.nih.gov/books/NBK537336/

24. Richard, F. 2018, Why we should be against the medicalisation of Female Genital Mutilation, International Health Policies: https://www.internationalhealthpolicies.org/blogs/why-we-should-be-against-the- medicalisation-of-female-genital-mutilation/

25. Scorgie, F. et al, 2010, "Cutting for love”: genital incisions to enhance sexual desirability and commitment in KwaZulu-Natal, SouthAfrica : https://www.tandfonline.com/doi/full/10.1016/S0968-8080(10)35500-5

26. Thomas, L., 2018, Labia Stretching: https://www.news-medical.net/health/Labia- Stretching.aspx

27. UNHCR, 2001, Guinea: Report on Female Genital Mutilation (FGM) or Female Genital Cutting (FGC): https://www.refworld.org/docid/46d5787832.html

28. UNICEF, unknown year of publication, Priorities in child survival, education and protection, https://www.unicef.org/wcaro/WCARO_Niger_Factsheet-11.pdf (accessed on 21/09/19)

29. Wahlberg A. et al, 2017, Factors associated with the support of pricking (female genital cutting type IV) among Somali immigrants, Reproductive Health, 14: 92: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5549348/#CR5 (accessed on 21/09/2019)

30. WHO, 2008, Eliminating Female genital mutilation: An interagency statement

31. WHO, 2018, Female genital mutilation: https://www.who.int/news-room/fact- sheets/detail/female-genital-mutilation

IF YOU HAVE RESOURCES ON TYPE IV FGM & OTHER FEMALE GENITAL ALTERATIONS - PLEASE SHARE THEM!

September 2019

W W W . C O P F G M . O R G The Debates of the Community of Practice on FGM

FGM Type IV and other forms of female genital alterations CoP FGM, September 2019

The Community of Practice on FGM is part of the Building Bridges between Africa and Europe to tackle FGM project, supported by the UNFPA-UNICEF Joint programme on FGM.

The views expressed in this document are those of the authors and do not necessarily reflect the official policy or position of the UNFPA, UNICEF or any other agency or organization.