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Home , Clitoridectomy, Guinea (region), Infibulation, Sudan (region), West Africa

Female Circumcision: The History, the Current Prevalence and the Approach to a Patient Jewel Llamas April 2017

Introduction media, travel and international migration, Female circumcision, also known as female widespread awareness (beyond the of its genital mutilation (FGM) or female genital cutting practice) of the history and beliefs that perpetuate (FGC), is practiced in many countries spanning this tradition is essential. This paper offers a guide parts of , the and Southeast . to help practitioners understand the terminology, Over 100 million women and young girls living classifications, origin, proposed purposes, current today have experienced some form of FGM with distribution and prevalence of FGM, closing with millions more being affected annually. With the recommendations for obtaining a history from and becoming a smaller and smaller place via conducting a pelvic exam on this patient population.

Terminology and Classifications

The practice of female genital alterations has procedures involving partial or total removal of the been referred to by many different names. The external genitalia or other injury to the female conducted their earliest studies on genital organs for non-medical reasons.”3 these practices using an anthropological approach, With the establishment of its internationally- adopting the term “female circumcision,” which the accepted definition came the differentiation of four World Health Organization adopted as well. separate types, or severities, of FGM seen in However, many believed this term euthanized and practice: “normalized” the practice, making it comparable to  Type 1: Only Prepuce removal or prepuce removal plus partial or total removal of the (also referred to as )  Type 2: Removal of the clitoris plus a portion of or all of the minora (excision)  Type 3: Removal of a portion of or all of the with the being sewn together, covering the urethra and and leaving small opening for urination and menstruation ()  Type 4: All other harmful procedures to widely accepted male circumcisions. In the mid the female genitalia for non-medical 1970s, feminist activists of the time emphasized the purposes including pricking, piercing, harmful consequences this tradition could have on incising, scraping and cauterizing its recipients. Accordingly, to recognize the damage done to normal, healthy tissue, they began using the However, this terminology is not accepted by term “mutilation” versus “circumcision.”1 Since the all, especially by those who originate from areas 1990s, “female genital mutilation” (FGM) has been where these practices occur. In one ethnographic widely accepted.2 Its current formal definition is “all study conducted in , participants often found the term “mutilation” offensive, suggesting 1

“intentional harm” and “evil intent.” These used but only one will be suggested for patient participants preferred the term “female interactions. circumcision.”2 In this paper, both terms will be

Origin of the Practice

Location implemented on female slaves in , deterring recipients from coitus and subsequent The exact origin of female genital mutilation . 1 (FGM) remains unclear. Some scholars have With its widespread prevalence, a “multi-source proposed Ancient Egypt (present-day Sudan and origin” has also been proposed, claiming that FGM Egypt) as its site of origin, noting the discovery of spread from “original cores” by merging with pre- circumcised mummies from fifth century BC. Other existing initiation rituals for men and women.4 scholars theorize that the practice spread across the Despite the perplexity surrounding its origin, the routes of the slave trade, extending from the practice of FGM endears across the globe, serving western shore of the to the southern, several theoretical purposes for the communities western African regions, or spread from the Middle that propagate its practice. to Africa via Arab traders.1,4 The practice was also

Figure 2. Geographic Distribution of Female Genital Mutilation7

“sexual propriety” and “morality,” “demonstrating Proposed Purposes of FGM the obedience and respect required for marriageability.” 4 In the highly structured social For the regions where FGM originated, scholars framework of the ancient Egyptian , FGM have proposed three functions for this practice. The was implemented as a means of perpetuating first draws from the theories behind the inequality between the classes, with cutting “marriageability” of a woman, emphasizing the young girls and women, signifying their ideologies of “virginity, purity, and sexual restraint” commitment to the wealthy, polygamous men of that are upheld in the societies where FGM is their society. 4 practiced. By reducing (or increasing, depending However, female circumcision is practiced on the cultural group) sexual pleasure, the today in areas where female premarital sexual procedure protects young girl’s and women’s intercourse is permitted, such as the Rendille 2

women of Kenya. In such areas, the practice is it from contact with the penis, doctors removed the thought to serve its second proposed purpose: a adhesions between the clitoris and its hood or means of solidifying ones “cultural identity” and removed its hood completely. According to transition to being an “adult member of society.” gynecologist, Dr. Howard Kelly of Johns Hopkins For example, the name of the “Kipsigis” of Kenya University, the adhesions between the clitoris and translates to “we the circumcised,” as, after hood were also believed to cause “irritation,” circumcision, one is thought to be “reborn.”4 In leading to . If proficient cleaning was areas where FGM is a tradition, parents fear their insufficient treatment, circumcision was deemed an daughter will be banned from their society.5 appropriate alternative treatment.6 Its third possible function surrounds the idea of Table 1. Female Genital Mutilation protecting the health of women and their fetus. In Prevalence among Girls 0 to 14 Years of Age7 some cultures, FGM is believed to improve hygiene Country Prevalence (%) and increase a woman’s probability of conception Gambia 56 with intercourse. In addition, physical contact 54 between the “toxic” clitoris and a baby during Indonesia 49 is thought to be potentially fatal to the 4 46 fetus. The procedure also conserves the recipient’s 33 attractiveness, as the clitoris could potentially grow Sudan 32 until it “touches the ground.”5 Guinea- 30 Cases of female genital mutilation were reported for centuries in European countries as well. Interest 24 in the practice grew in the 1860s when Isaac Baker 17 Brown –the founder of the London Surgical Home Egypt 14 for Women –noted that female epileptics in his 13 hospital tended to masturbate. From this 13 observation, he concluded that masturbation led to Côte d'Ivoire 10 hysteria, then and subsequent “idiocy and Kenya 3 death.” Brown believed the only cure for this path Central African Republic 1 to “feminine weakness” and death was 1 clitoridectomy, which gained widespread Uganda 1 2 acceptance. 0.3 In the late nineteenth century, in Western 0.2 cultures its primary function unfolded to become a means of regulating certain sexual practices After analyzing these practices of (particularly female masturbation, “hysteria,” and American obstetricians that extended as late lesbianism) and clitoral enlargement.1,5 as the 1960s, Sarah Rodriguez concluded Masturbation was seen as a disorder with treatment Western practices of FGM emphasized the being reserved for its most severe cases. In 1896, need to control female sexuality and align its for a twenty-nine year old, single female living in with a purpose beyond women’s own Brooklyn, New York, this meant obtaining a desires: the purpose of contraception and clitoridectomy when her concerned father told their wifely duties.6 American ’ doctor, Dr. John Polak, about her acts of rationale for FGM closely mirrored the masturbation twenty to forty times a day. values of hygiene, purity, sexual restraint, In the late nineteenth century, a wife’s failure to and marital commitment that brought FGM enjoy coitus with her husband was also seen as to existence thousands of years evidence of a disorder in . Thought to be secondary to the hood of the clitoris separating

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of female genital mutilation .7 Two million more Table 2. Female Genital Mutilation Prevalence females are considered at risk of undergoing FGM among 2 7 annually. Young girls typically undergo FGM prior Girls and Women 15 to 49 Years of Age to puberty, between six and twelve years of age. Country Prevalence (%) In some cultures, the procedure may be performed 5 98 at birth, at menarche or prior to marriage. Guinea 97 The prevalence of the four different types of 93 FGM varies geographically. Type I is mostly 90 practiced in Ethiopia, Eritrea and Kenya; Type II, in 89 regions of such as Benin, Sierra Leone, Egypt 87 Gambia and Guinea; Type III, in Somalia, Northern Sudan 87 Sudan, eastern , southern Egypt, and Djibouti Eritrea 83 and Type IV in Northern Nigeria.2,5 Eighty percent Burkina Faso 76 of Type III, the most severe type, occurs in Gambia 75 Somalia.2 According to UNICEF’s global databases Ethiopia 74 of 2016, the practice of FGM on girls up to fourteen Mauritania 69 years old is most prevalent in Gambia (56% of the 50 age group), Mauritania (54%) and Indonesia (49%) Guinea-Bissau 45 (Table 1).7 Among 15 to 49 year old females, FGM Chad 44 is mostly heavily practiced in Somalia (98%), Côte d'Ivoire 38 Guinea (97%) and Djibouti (93%) (Table 2).7 Nigeria 25 Midwives or trained circumcisers travel across Senegal 25 several villages, conducting the without Central African Republic 24 anesthesia, antibiotics or sterile equipment.5 Kenya 21 Although the majority of women in many of these Yemen 19 countries now believe the practice should be ended, United Republic of Tanzania 15 some still believe in the tradition. Further Benin 9 complicating efforts for its global eradication, the Iraq 8 majority of girls and women in Guinea (76%), Mali Togo 5 (73%), Sierra Leone (69%), Somalia (65%) and Ghana 4 Egypt (54%) still support the tradition (Table 3).7 2 With the persistent practice of female 1 circumcision and the increase of international Uganda 1 migration, awareness outside of the realms of its

The of the Practice Today practice is essential in order to provide these women with proper, culturally-sensitive care. Advances in disproving the beliefs behind FGM in Western Culture, many cultures Approach to a Patient with a History of Female Circumcision now denouncing the practice due to advances in women’s rights, the United Nations General Assembly adopting a ban of female genital Obtaining a History When an immigrant or refugee settles in a new mutilation in December of 2012—despite all of country, a general practitioner is often the first these factors, this practice still persists in twenty- medical provider they see. Nonetheless, many nine countries spanning Africa, parts of the Middle obstacles can impede a ’s ability to East and Southeast Asia (Yemen, Iraq, Indonesia 1 identify a woman or child’s history of female and Malaysia) (Figure 2). Today, more than 125 circumcision. Firstly, the provider must be aware of million girls and women have suffered some form its risk factors: lineage to a community known to 4

practice FGM or a first- or second-degree, female of origin. In the Democratic Republic of Congo relative with a history of the procedure. Secondly, (DRC) (where the patient who ignited my interest in the practitioner must feel comfortable asking the FGM was from), forty percent of women and patient about female circumcision. As the lower twenty-four percent of men have suffered some types of FGM may be more difficulty to identify on form of . One study stated that physical exam, especially by more inexperienced approximately forty-eight women are raped every physicians, it is important to ask prior to hour in the DRC.8 examination.3 Furthermore, if the examiner does While some women may spontaneously share first recognize a history of FGM on exam and their history of sexual violence, others may be more appears alarmed or upset, this can be demoralizing reluctant to share such sensitive information, to the patient.9 especially at a first visit. Nonetheless, surveys have As previous studies have shown that the term shown that the majority of women with a history of “female genital mutilation” may offend some sexual trauma prefer routine inquiries versus having patients, I recommend referring to the practice as to mention the topic themselves.9 Accordingly, “female circumcision.” If a woman does have a asking about a history of sexual abuse is history of female circumcision, their chance of recommended, particularly with women who have having experienced another form of sexual violence not had routine pelvic examinations in the past or may also be increased, depending on their country appear more distressed than normal.

Table 3. Support for the Continuation of Female Genital Mutilation Among 15-49 Year Old Girls and Women7

Country Percentage of Support Guinea 76 Mali 73 Sierra Leone 69 Gambia 65 Somalia 65 Egypt 54 Mauritania 41 Sudan 41 Liberia 39 Chad 38 Djibouti 37 Ethiopia 31 Nigeria 23 Yemen 19 Senegal 16 Côte d'Ivoire 14 Guinea-Bissau 13 Eritrea 12 Central African Republic 11 Burkina Faso 9 Uganda 9 Cameroon 7 Kenya 6 Niger 6 United Republic of Tanzania 6 Iraq 5 Benin 3 Ghana 2 Togo 1

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While obtaining a patient’s history, physicians from unsanitary equipment, , must also inquire about a number of possible anorgasmia or complications with pregnancy and immediate and long-term complications of the childbirth.3 various types of FGM. Due to the psychological effects of dyspareunia Immediate side effects of FGM include pain, and the anatomic scarring from the procedure, thirty infection, hemorrhage, emotional and physical percent of women who undergo infibulation (Type shock, and damage to approximating organs, such III of FGM) are infertile. If a patient does become as the urethra or bowel.3 If the urethral or vaginal pregnant, infibulation increases her chance of many openings are obstructed, the patient may develop obstetric complications: postpartum hemorrhage, urinary retention, amenorrhea, or , , cesarean delivery, other subsequent problems.2 Long-term sequelae of extended hospital stay, stillbirth and neonatal the procedure could include chronic vaginal death.5, 2 infections, chronic urinary tract infections resulting in scarring and impaired renal function, blood-born viral infections (HIV, Hepatitis B or hepatitis C)

Approach to the Pelvic Exam not want the patient to be surprised and ultimately According to the Women’s Preventative feel violated, diminishing patient-physician trust. Services Guidelines, during a routine, preventive This also gives the patient the opportunity to women’s health evaluation, women should be express concerns or decline portions of the exam, if screened routinely for cervical , sexually she so desires. Her expression of her concerns allots transmitted infections, and domestic or the provider another opportunity to elaborate on interpersonal violence.10 Many of these components aspects of exam that make the patient feel most of the visit may make any patient feel uncomfortable. uncomfortable and vulnerable. For women with Even with proper education and consent, history of FGM or sexual trauma, pelvic speculum and digital examination may still awaken examination could be particularly distressing. flashbacks of their trauma, igniting anxiety and fear Considering this truth, Bates et al. of the before, during and after the procedure. Department of and Gynecology at Beth “Dissociation” during the exam may occur while Israel Deaconess Medical Center of Boston, examining victims of trauma. Signs of this include Massachusetts, sought to analyze all of the developing a childlike voice or having a “startle components the pelvic exam, delineating techniques response” to noises in the room or clinic. If this for minimizing discomfort and optimizing occurs, the exam should be stopped and the patient, culturally-sensitive care.9 once reoriented, should be offered mental health Firstly, to avoid placing a patient in a vulnerable resources. 9 position prior to obtaining consent, they suggest If the patient has had infibulation, pelvic conducting patient education while the patient is examination may be physically impossible or sitting upright and still fully clothed.9 Because of significantly painful for the patient, due to scarring the increased vulnerability of this population, taking with secondary vaginal and introital stenosis. In extra time to fully explain the components of the such cases, the patient should be referred to a exam in the patient’s preferred (using an gynecologist with experience working with this interpreter, if indicated) is essential, as one would population, if possible. 9 A full outline of recommendations is provided in Appendix A.

Conclusion identity of twenty-nine nations worldwide, affecting Female genital mutilation and circumcision is a millions of young girls and women every year. With tradition embedded deeply in the culture and the significant number of immigrants and refugees 6

in the United States, one’s probability of seeing a must be spread, assuring that knowledgeable, patient who has undergone some type of FGM is empathetic, culturally-sensitive care is provided to not insignificant. Accordingly, more awareness of this potentially vulnerable population. the complex history and complications of FGM

Bibliography and Allied Sciences. 2008;63(3):323-347. doi:10.1093/jhmas/jrm044. 7. Female Genital Mutilation and Cutting. UNICEF DATA. 1. Andro A, Lesclingand M. Female genital mutilation. Overview https://data.unicef.org/topic/child-protection/female-genital- and current knowledge. Population. 2016;71(2):215-296. mutilation-and-cutting/. Published September 2016. Accessed 2. Gruenbaum E. The female circumcision controversy: an March 26, 2017. anthropological perspective. Philadelphia: University of 8. Congolese Refugee Health Profile. Centers for Disease Control Pennsylvania Press; 2001. and Prevention. 3. Female Genital Mutilation: A clinical approach for GPs. Royal https://www.cdc.gov/immigrantrefugeehealth/pdf/congolese- College of General Practitioners. health-profile.pdf. Published March 1, 2016. Accessed March http://www.rcgp.org.uk/policy/rcgp-policy-areas/female-genital- 24, 2017. mutilation.aspx. Accessed March 25, 2017. 9. Bates CK, Carroll N, Potter J. The challenging pelvic 4. Ross CT, Strimling P, Ericksen KP, Lindenfors P, Mulder MB. examination. Journal of General . The Origins and maintenance of female genital modification 2011;26(6):651-657. doi:10.1007/s11606-010-1610-8. across Africa. Nature. 2016;27(2):173-200. 10. Women's Preventive Services Guidelines. Health Services & doi:10.1007/s12110-015-9244-5. Resources Administration. 5. Nour NM. Female Genital cutting: A persisting https://www.hrsa.gov/womensguidelines2016/index.html. practice. REVIEWS IN OBSTETRICS & GYNECOLOGY. Accessed March 30, 2017. 2008;1(3):135-139. 11. Classification of FGM Photo. Newsnet One: Breaking Barriers- 6. Rodriguez SW. Rethinking the History of Female Circumcision Building Community. http://newsnetone.com/2017/02/female- and Clitoridectomy: American medicine and female sexuality in the late nineteenth century. Journal of the genital-mutilation-and-us/ Accessed April 5, 2017.

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Appendix A10:

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