From choice, a world of possibilities
December 2008
BRIEFING Paper Female genital mutilation (FGM) Annual Report 2006 From choice, a world of possibilities
IPPF’s suite of policy Contents resources includes • What is female genital mutilation? factsheets, briefing • IPPF and female genital mutilation papers and discussion • Origins of FGM and common justifications papers that provide • Consequences: Poor health, emotional suffering and lost evidence-based opportunities throughout life information, analysis • Extent of the problem and guidance on key From choice, a world of possibilities issues related to sexual • FGM is a violation of women’s rights, children’s rights, human rights and reproductive • Progress in the campaign to end FGM health and rights. • Recommendations and statements on the elimination of FGM • Future directions • A note on terminology • References
creating a covering seal through the cutting and apposition of What is female the labia. This may be done with genital mutilation? or without the removal of all or part of the clitoris. This type of Female genital mutilation (FGM) is FGM – often called infibulation “the partial or total removal of the – constitutes 15 per cent of all external female genitalia or other procedures. injury to the female genital organs iv. The final type involves all other for non-medical reasons.”1 harmful procedures done to female genitalia for non-medical There are four different types of FGM: purposes, including pricking, piercing, incision, burning, i. The partial or total removal of the branding and scraping.2 clitoris and/or the area surrounding and protecting the clitoris. Traditionally, the procedure is carried out by women with no medical ii. The partial or total removal of the training. Anesthetics and antiseptic clitoris and the removal of the treatment are not often used and labia. This is the most common the practice may be carried out using type of FGM and accounts for up basic tools such as scissors, knives, to 80 per cent of cases. scalpels, pieces of glass and razor iii. The third type involves the blades. Iodine or a mixture of herbs is narrowing of the vaginal orifice by often placed on the wound to tighten 02 Briefing Paper – Female genital mutilation (FGM)
the skin in and around the vagina and Female genital mutilation is a direct entrenched in social, economic, stop the bleeding. In recent years, the violation of a number of sexual cultural and political structures, procedure has been medicalized in rights, which have been identified in and the procedure is often accepted some regions and it is carried out in Sexual Rights: An IPPF Declaration. without question. Some social health care facilities by trained health These include: article one – the right justifications that are held by groups care personnel. to equality, equal protection of the that defend the practice include: law and freedom from all forms of - Preservation of virginity and The age at which female genital discrimination based on sex, sexuality ensuring fidelity mutilation is carried out varies or gender; article three – the rights to from one region to another. It is life, liberty, security of the person and - Identification with cultural heritage carried out on infants just a few bodily integrity; article five – the right - To mark the transition of girls days old, children, adolescents and, to personal autonomy and recognition into womanhood occasionally, on mature women. before the law; article seven – - Social integration and acceptance, In some cultures that practise FGM, the right to health and to the benefits particularly for marriage and women are re-infibulated (re-stitched) of scientific progress; and article ten – family honour following childbirth. 3 the right to accountability and redress. - Hygiene and cleanliness FGM as a violation of human rights is - Enhancing fertility and discussed in detail below. infant survival IPPF is driven to achieve its vision - Increasing sexual pleasure for IPPF and female through sustained efforts to eliminate the male (the husband) FGM. It does this work in close - Religion genital mutilation partnership with stakeholders including other service providers and advocates, IPPF views female genital mutilation While religious justifications across international organizations, donors, (FGM) as a harmful practice Christian, Jewish, Muslim and certain governments, non-governmental that negates IPPF’s vision of indigenous African groups are often organizations and the women, men a world in which all women, men used, it must be noted that none of and young people that we serve. and young people have access to the the holy scriptures of Christianity, 6,7 information and services they need; Judaism or Islam advocate for FGM. a world in which sexuality is recognized El-Saadawi, author of The Hidden as a natural and precious aspect of Face of Eve: Women in the Arab World, writes: life and as a fundamental human Origins of FGM and right; a world in which choices are Religion, if authentic in the fully respected and where stigma and common justifications principles it stands for, aims at discrimination have no place. truth, equality, justice, love and Evidence from Egyptian mummies a healthy wholesome life for all FGM is a crime against the human suggests that a form of FGM was people, whether men or women. rights of women. By denying women routinely practised some 5000 years There can be no true religion that and girls equal sexual expression and 4 ago. In ancient Rome, metal rings aims at disease, mutilation of the pleasure, it reinforces the subordination were passed through the labia of bodies of female children, and and victimization of girls and women, female slaves to prevent them from amputation of an essential part and is directly linked to poor sexual and procreating. The United Kingdom of their reproductive organs.8 reproductive health. FGM raises the in the 19th century allowed the question of basic rights of women and surgical removal of the clitoris as A complex interaction of socio-cultural girls, such as equality of opportunity, an accepted technique for the factors exerts pressure on mothers full citizenship and the right to health, management of epilepsy, sterilization and families not to break the custom including sexual and reproductive and masturbation.5 In Africa and the of passing the tradition of FGM from choice. FGM is an act of violence that, Middle East, FGM is thought to have generation to generation. Even when while often justified by tradition, culture taken root centuries ago. Yet even parents know the harm that FGM or religion, serves only to support in those regions, there are some will cause to their child, they feel patriarchal dominance and structures countries where the practice began pressured to keep with tradition as within society and undermines the role relatively recently. the individual harm (often considered of women. FGM ignores a woman’s limited and of short duration) is seen or girl’s right to privacy and bodily Reasons that have been offered to as less damaging than the ostracism integrity, and directly contradicts the justify FGM are complex and vary and social stigma a girl may face principle of non-discrimination. according to tribal roots and ethnic within the community if she does not traditions. Explanations regarding the undergo FGM. In communities where utility and purpose of FGM are usually FGM is the norm, a girl that has not Briefing Paper – Female genital mutilation (FGM) 03
undergone FGM may have no chance Recurring infections can cause chronic at social acceptance or marriage. pelvic and back pain. FGM increases As such, she may pose a lifelong Consequences: the risk of urinary tract infections burden to her parents and the choices Poor health, emotional which can affect the bladder and that are open to her to pursue her kidneys, and may lead to fatal aspirations and/or to form her own suffering and lost complications. FGM may also result in family will be limited. incontinence, sexual dysfunction and opportunities infertility. Irritation and inflammation In some areas where FGM is practised, throughout life may result in retention of urine and it has been integrated into the health menstrual blood. Women who have care arena. This medicalization of The immediate and long-term undergone FGM are at higher risk of the practice is likely a result of the health consequences of FGM vary complications during childbirth, such emphasis that campaigners have according to the type and severity as obstructed labour, perennial tears, placed on the negative health of the procedure performed. Even if the need for a caesarean section or implications of FGM. This has occurred no complications arise, once tissue haemorrhage after giving birth. in several countries, including Egypt, is removed it can never be replaced, Ethiopia, Kenya, Nigeria and Senegal. resulting in life-long physical change. Adverse physical consequences are Medicalization of the procedure Complications are common as many only part of the damage that a girl is particularly common in Egypt, of the procedures are performed or woman may suffer as a result of where up to three quarters of FGM by untrained practitioners or family being mutilated. A wide variety of procedures are performed by trained members, without anaesthesia, and psychological and psychosomatic medical personnel. Even in rural Upper using non-surgical and unsterilized disorders have been attributed to Egypt, where FGM is performed implements including razors, knives the practice, including depression more commonly by traditional health or broken glass. and symptoms of impaired cognition attendants, the majority are still that include sleeplessness, recurring carried out by health care providers.9 Immediate complications include nightmares, loss of appetite, weight While it may reduce the physical shock, severe pain and haemorrhage, loss or excessive weight gain, health impact, the medicalization which can lead to death. Swelling can and panic attacks.11 The extent of of FGM ignores the human rights make urination and defecation painful. psychological trauma can be difficult violations that are inherent in the Healing can take up to eight weeks, to ascertain as the effects are procedure as well as the social or longer, depending on the severity often subtle and may not be and mental health consequences. of the procedure. Infections are easily diagnosed. Because it may appear to be a positive very common and can lead to fatal development, the medicalization of septicaemia, tetanus or gangrene. Loss of opportunity is a frequently FGM hinders the campaign to end neglected consequence of the the practice. Long-term or delayed complications medical and psychological problems can occur at any time in the life of ascribed to FGM. FGM and its IPPF endorses the joint statement a woman who has been mutilated. implications can have a significant of WHO and other United Nation These complications include severe impact on a girl’s education, resulting agencies that FGM is an unjustifiable pain and tenderness over the scar in absenteeism, poor concentration, and harmful practice which must tissue, which can make sexual low academic performance and loss be eliminated,10 and recognizes intercourse painful, even when the of interest.12 Lost opportunities in that an understanding of the above vaginal opening is large enough education, employment, health and justifications is critical to any work to allow penetration. Penetration social activity, and the consequences designed to eliminate the harmful attempts through a narrowed of these lost opportunities, endure practice. In particular, researchers vaginal opening (infibulation, or long after the mutilation has been should explore how socio-cultural type three) is extremely painful and carried out, affecting girls and beliefs about female sexuality, may lead to tearing of the skin and women throughout their lives. sexual morality and femininity internal bleeding, both of which affect women’s support of FGM. require medical intervention. Painful intercourse and excessive scarring can adversely affect sexual sensitivity and pleasure, and can negatively impact a girl’s psychological and psychosexual development. 04 Briefing Paper – Female genital mutilation (FGM)
by those 28 countries where FGM is most prevalent – are needed to make Extent of the problem FGM is a violation progress in ending the practice.
WHO estimates that between 100 of women’s rights, and 140 million girls and women children’s rights, worldwide are living with the consequences of FGM today.13 human rights Progress in the Every year about three million girls and women, the majority under 15 FGM violates a series of well- campaign to end FGM years of age, undergo the procedure.14 established human rights principles, norms and standards, including For over 50 years, many international FGM predominately occurs in 28 the principles of equality and and national, governmental and countries in Africa and the Middle non-discrimination on the basis of non-governmental, organizations and East; they span a belt running from sex, the right to bodily integrity, agencies have established programmes Senegal on the west coast of Africa the right to life (in cases where the to eliminate FGM. Due to their efforts, to Ethiopia and Somalia in the procedure results in death), and the many international legal instruments east, where Egypt juts to the north right to the highest attainable standard and national legislations now include and Kenya and United Republic of of physical and mental health. clauses prohibiting the practice. Tanzania extend to the South. Given that children are frequently However, the practice remains highly Of these 28 countries, nearly half of subject to the procedure, FGM also prevalent in 28 countries across Africa all FGM occurs in Egypt or Ethiopia. violates the rights of the child. The and the Middle East, despite the Recent survey data for 18 of these Convention on the Rights of the Child fact that half of these nations have 28 countries show the prevalence makes explicit reference to harmful introduced legislation forbidding FGM. of FGM to range from five to 97 traditional practices, and calls upon Only four of these countries have per cent of the female population.15 all countries to take effective and brought forward prosecutions.17 This Some countries on the Red Sea appropriate measures to abolish them. highlights the need for more than coast, such as Yemen, are known The eradication of FGM is supported just legislative action. to practise FGM and incidents are by a number of conventions, and also reported in Jordan, Oman, the international, regional and national Palestinian territories (Gaza) and agreements. The Protocol to the in certain Kurdish communities in African Charter on Human and Iraq. The practice has been reported Peoples’ Rights on the Rights of Recommendations among groups in India, Indonesia Women in Africa (also known as the and Malaysia. Increasing numbers ‘Maputo Protocol’) urges governments and statements on the of girls and women who have been to combat all forms of discrimination elimination of FGM subjected to the procedure are seen against women, particularly harmful in Australia, Canada, Europe and the practices that endanger the health IMAP statement on the USA, generally among immigrants and general well-being of women, elimination of FGM from countries where FGM is widely through legislative and regulatory In October 2007, IPPF’s International practised. It is widely recognized that measures. It asks nations to “commit Medical Advisory Panel (IMAP) issued female genital mutilation is practised themselves to modify the social a statement on the elimination of by specific ethnic groups, rather than and cultural patterns of conduct of FGM. The IMAP statement makes by whole countries, as communities women and men through public recommendations to IPPF Member that practise FGM cross national education, information, education and Associations on activities they should boundaries. communication strategies, with a view undertake to eliminate FGM. to achieving the elimination of harmful cultural and traditional practices.”16 As a starting point, Member Attempts to eliminate FGM implies Associations should conduct research compliance with agreements signed to obtain all available information in the forums of the United Nations on the prevalence, dynamics and including UNFPA, UNIFEM, WHO and characteristics of FGM in their UNICEF, European Union, Inter-African own countries. Then, within their Commission on Traditional Practices specific social and cultural contexts, and the African Union, among others. Member Associations should review Action plans and financial resources – their current activities, familiarize agreed internationally, but particularly themselves with the available Briefing Paper – Female genital mutilation (FGM) 05
resources to eliminate FGM, and and reproductive complications - the commitments, relevant to develop strategies to eliminate the commonly associated with FGM, the girl child, made at the United practice. IMAP emphasizes that which they may encounter, before Nations General Assembly special sustained action is necessary to these girls and women have sex for session on children (2002) ensure long-term impact. the first time and before they become pregnant. IMAP also advises Member - the United Nations General IMAP specifically advises Member Associations to provide information Assembly resolution 60/1 on the Associations to: train service providers regarding the risks of childbirth 2005 World Summit Outcome in human rights and the harms of for women who have undergone Through the statement on FGM, FGM; encourage government and FGM, and to encourage pregnant the World Health Assembly calls law-enforcing bodies to clarify and women who have undergone FGM to on all member states to: enforce existing laws against FGM; deliver their babies in clinical settings and collaborate with governments, where any complications could be (1) accelerate actions towards NGOs and religious and community properly managed. Lastly, Member the elimination of female genital leaders to raise awareness of the Associations should ensure that a mutilation, including education negative impact of FGM and to dispel referral system is in place if counselling and information necessary for full relevant justifications or myths about and care services for girls and women understanding of the gender, health the procedure. who have undergone FGM are not and human rights dimensions of available at the service delivery point. In countries where FGM is practised female genital mutilation; within immigrant communities, All women, including those who (2) to enact and enforce legislation Member Associations should mobilize have been mutilated, must have to protect girls and women from immigrant communities to be active access to sexual and reproductive all forms of violence, particularly participants in behaviour change health services, including testing, female genital mutilation, and activities, including through the contraception and education. ensure implementation of laws delivery of accurate information and IMAP advises that all data relating prohibiting female genital mutilation education. Member Associations to the prevalence and health by any person, including medical should involve women in their efforts, consequences of FGM victims should professionals; in particular female health workers and be collected and used in advocacy to women community leaders. support change. (3) to support and enhance Men should also be involved in community-based efforts to eliminate behaviour change activities, as World Health Assembly the practice of female genital their buy-in and support is equally The 61st World Health Assembly mutilation, particularly ensuring men’s important to bring about an end to the issued a statement on female genital and local leaders’ participation in the practice. Member Associations should mutilation in May 2008. The Assembly process to eliminate the practice; implement broader reproductive stated that the outcome documents health programmes that include from a number of international events (4) to work with all sectors of discussions of FGM and promote together form an essential framework government, international agencies activities to end the practice, and they for advancing the rights of women and nongovernmental organizations should train service providers to use and girls and eliminating female in support of the abandonment of every opportunity to counsel women genital mutilation. The outcome the practice as a major contribution and their partners on the issue. documents identified by the World to attainment of the Millennium Health Assembly are the: Development Goals on promoting In countries where FGM is widely gender equality and empowerment of practised, IMAP strongly recommends - Beijing Declaration and women, reducing child mortality, and that Member Associations include Platform for Action of the Fourth improving maternal health; FGM-related programming as an World Conference on Women integrated part of a comprehensive (Beijing, 1995) (5) to formulate and promote mix of services. Specifically, Member guidelines for the care, particularly Associations should train health - the Programme of Action of during childbirth, of girls and women professionals to provide counselling the International Conference who have undergone female genital and care for the physical and on Population and Development mutilation; psychological complications of (Cairo, 1994) and their five- FGM, or they should refer clients and ten-year reviews for specialist care. Counselling - the United Nations Millennium for mutilated women (and their Declaration 2000 partners) should highlight the sexual 06 Briefing Paper – Female genital mutilation (FGM)
(6) to develop or reinforce social and religious teachings. Nurses, and psychological support services midwives and doctors, when they are and care and to take measures to Future directions themselves fully aware of FGM and improve health, including sexual and its implications, can facilitate and aid reproductive health, in order to assist While the elimination of FGM teachers with such education. women and girls who are subjected to continues to be a difficult challenge, this violence. progress is occurring. One encouraging Medical education is important trend seen consistently in countries both during initial training and in The full statement is available on the where FGM is practised, for which ongoing professional development, World Health Organization’s website data are available, is that women as many nurses and midwives are at: www.who.int/gb/ebwha/pdf_files/ aged 15-19 years are less likely to have ill-prepared to deal with FGM at the A61/A61_R16-en.pdf been subjected to FGM than women level of prevention, management and aged 20 years and older.18 Efforts to counselling. FGM should be included The World Health Organization’s eradicate FGM must continue and new as a specific topic in nursing and response to FGM strategies must be developed in order midwifery curricula in all countries The World Health Organization (WHO) to end this devastating practice. where FGM is a problem, including has released several statements countries where it is seen only among condemning the practice of FGM and Legal approaches to reducing migrant populations, so that health it continues to campaign for an end incidents of FGM providers are sensitive to the needs to the practice. WHO has reviewed While advocating for laws restricting of clients who have undergone programmes on the eradication of or outlawing FGM may be effective in the procedure. Doctors also need FGM and has published a review reducing prevalence of the practice, adequate information. For example, on what works and what does not. care must be taken to ensure that in Egypt, human sexuality and the It has also published a guide to the legislation does not drive FGM functions of the female external management of pregnancy, childbirth underground or encourage cross- genitalia is not taught in medical and the postpartum period in the border movement of women from a schools or any other schools or presence of FGM; a set of training country where the procedure is illegal colleges.19 In countries where FGM is manuals for nurses and midwives, to a neighbouring country where it is highly medicalized, doctors and nurses teachers and students; a systematic allowed. Even though anti-FGM laws are complicit. In these circumstances, review of the health implications have some disadvantages, activist relevant professional bodies should of FGM; the results of a study in and grassroots non-governmental implement ethical guidelines and six African countries on FGM and organizations generally agree that a impose penalties on practitioners who obstetric outcome; and a progress law provides a back up to their work violate them. Education on FGM for newsletter on the practice. These are by empowering them with legal traditional birth attendants is also available through WHO’s website at support and, ostensibly, the support essential, especially in resource-poor www.who.int/reproductive-health/ of their governments. settings where pregnant women have fgm little or no access to formal health In countries that enforce laws care. Their training should also be restricting FGM, it is difficult to periodically re-assessed. Training, find the right balance between updating and supervision currently enforcement, community education vary from area to area. Demand and dialogue. and need for training and education Education should be reviewed in different While the law is important, education areas, taking into consideration is key to the elimination of FGM. the prevalence of FGM within the community and with regard to Public education in the broadest existing health care resources. sense is vital in producing behaviour change, and is essential to the FGM practitioners must also be success of the campaign to end FGM. educated about the consequences Education about FGM prevention of their actions and the violation of should be encouraged in schools. fundamental human rights that is Reproduction and FGM related inherent in the mutilation they inflict. problems should be integrated into During and after this education is science; biology and hygiene lessons; provided, information and resources personal, social and gender education; should be provided to practitioners about other income-generating Briefing Paper – Female genital mutilation (FGM) 07
activities and jobs so that they can Female genital mutilation is the most more easily choose not to continue accurate description of the procedure the practice. A note on terminology and thus, this is the term used by IPPF. We anticipate that by using the term Collaboration with Female genital mutilation is known ‘female genital mutilation’ we will public, private and non- by a number of names, including broaden and deepen awareness of the governmental stakeholders female genital cutting and female procedure and its implications. In order to develop strong circumcision – both of which are not educational strategies, there is a acceptable terms. Neither of these Gita Sen says, “The argument of need for collaboration between names reflect the true horror and cultural diversity has been effectively government bodies, private sector, impact of the procedure on the girls used as a screen to justify and non-governmental organizations and women who are subjected to it. perpetuate even the grossest and research institutions, including violation of women’s humanity.”20 biomedical and social science Additionally, ‘female genital cutting’ Women from developing countries researchers who have linkages to over-simplifies the procedure and are themselves demanding an end relevant communities. it does not encompass the range to FGM. They are demanding their of methods that may be used to human rights. Governments that have made FGM alter female genital tissue. ‘Female illegal must be held accountable to circumcision’ is misleading because enforce the law, including developing it may incorrectly align the procedure and developed countries. Civil with male circumcision, which society has a duty to monitor the is a relatively harmless process implementation of laws and policies that has been linked to positive that support the eradication of FGM. health outcomes.
Other approaches Some groups argue that female Other important strategies to genital mutilation is an inappropriate eradicate FGM include: finding term as some audiences may infer alternative sources of income for that the intent to mutilate, which is FGM practitioners; economic and inherent in the procedure, extends to social empowerment for women; the cultures and contexts (in which the promotion of alternative rites this practice is prevalent) as a whole. of passage; group discussions Usage of this term has been labeled and media campaigns aimed at culturally insensitive, representing a raising awareness; promoting the broader sentiment and expression abandonment of FGM as part of a against such cultures and places, ‘development package’ that includes a including the people that are native to reduction of poverty and of inequities them, where the procedure is carried and inequalities between the sexes; out. These are incorrect inferences and an increase in access to education that must be corrected to the greatest and health services. The development extent possible. of innovative strategies and the scaling up and duplication of proven techniques to reduce FGM could prove enormously valuable in reducing the prevalence of FGM worldwide. Briefing Paper – Female genital mutilation (FGM) 08
References
1. World Health Organization (2008) Fact 15. World Health Organization (2006) A factual IPPF is a global service sheet: Female genital mutilation.
6. Aldeeb Abu-Sahlieh, S (1994) To 19. World Health Organization (1999) Female Mutilate in the Name of Jehovah or Genital Mutilation, Programs to Date: What Allah: Legitimization of Male and Female Works and What Doesn’t. WHO: Geneva. Circumcision. Medicine and Law, 13 (7-8), pp. 575-622. 20. Sen, G and Presser, H B (2000) Women’s Empowerment and Demographic 7. Broussard, P A (2008) Female Genital Processes: Moving Beyond Cairo. Mutilation: Exploring Strategies for Ending England: Oxford University Press. Ritualized Torture; Shaming, Blaming, and Utilizing the Convention Against Torture. Duke Journal of Gender Law and Policy, 15 (19), pp. 19-47.
8. Quoted in Aldeeb Abu-Sahlieh, S. Ibid.
9. El-Zanaty, F, Way, A and ORC Macro Calverton (2006) Egypt Demographic Health Survey 2005 – Final Report. Maryland, USA: Measure DHS.
10. ORCRH, UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCR, UNICEF, UNIFEM, and WHO. (2008) Eliminating Female genital mutilation: An interagency statement. World Health Organization: Geneva.
11. Behrendt, A and Moritz, S (2005) Post- traumatic stress disorder and memory Published in December 2008 by problems after female genital mutilation. International Planned Am J Psychiatry, 162 (5), pp. 1000-1002. Parenthood Federation
12. World Health Organization (2006) IPPF Terminology and the main types of female genital mutilation. Progress in Sexual and 4 Newhams Row Reproductive Health Research, 72, pp. 3. London SE1 3UZ United Kingdom 13. World Health Organization (2008) Ibid. tel +44 (0)20 7939 8200 14. World Health Organization (2006) Terminology and the main types of fax +44 (0)20 7939 8300 female genital mutilation. Ibid. email [email protected] web www.ippf.org
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