Female Genital Mutilation: Perspectives, Risks, and C o m p l i c a t i o n s Rita I. Morris Female genital mutilation, traditionally known as female circ u m- emale genital mutila- cision, is a surgically unnecessary modification of the female geni- tion (FGM), traditional- talia, practiced in nations in Africa, the Arab Peninsula, among some ly known as female cir- communities in Asia, and among immigrants and refugees fro m cumcision (FC), is a these areas who have settled in other areas. The practice is known Fs u rgically unnecessary modifica- a c ross socio-economic classes and among many diff e rent ethnic and tion of the female genitalia, cultural groups, including Christians, Muslims, Jews, and followers of practiced in 28 nations in the indigenous African religions. As people from these areas immigrate African continent, in a few to North America, health care professionals need to understand the countries in the Arab Peninsula, important aspects of this growing problem, including management among some communities in of complications, cultural attitudes, and sensitivities. Asia, and among immigrants and refugees from these are a s who have settled in Euro p e , Australia, and North America. cy or until the girl is of mar- ra. The raw surfaces of the two The practice is known acro s s riageable age, approximately 14 sides of the vulva are then socio-economic classes and to 16 years old; most common- s u t u red together obliterating the among many diff e ren t ethnic ly, between ages 4 to 12 years. i n t r oitus. A very small opening and cultural groups, including Type 1: (Sunna). C i r c u m- is left to allow for the flow of Christians, Muslims, Jews, and cision proper is excision of the urine and menstruation. Fifteen followers of indigenous African clitoral prepuce only. Clitori- p e rcent of all women who religions (Toubia, 1994). dectomy: part or the whole of experience female circ u m c i s i o n the clitoris is amputated and the have this type. Infibulation re p- Types of FGM/FC bleeding is stopped with pre s - resents 80%-90% of all female T h e re are four major types s u r e or with stitches. c i r cumcision in Sudan, Somalia, of female circumcision prac- Type 2: Excision (Inter - and Djibouti. ticed, three of which are most m e d i a t e ) . Involves the re m o v a l Type 4: Rare types of FGM or commonly practiced. FGM is of prepuce and glans clitoris m a n i p u l a t i o n . Gishiri cuts are the collective name given to together with the adjacent parts vaginal cuts made during labor several diff e r ent traditional of the labia minora. Bleeding is to relieve obstructed labor and practices that involve the cutting usually stopped with stitching, practiced only in Nigeria. In of female genitals. It is a tradi- but the vagina is not covere d . some communities the clitoris is tional ritual that pre p a r es girls Eighty-five percent of all not cut, but burned with a hot for their social roles as women. women who undergo female stone, pricked to let blood, or It is practiced as early as infan- c i r cumcision have either Type 1 washed with chemicals or or Type 2. herbs. In other communities no Type 3: Infibulation (Phar - cutting is employed but the onic circumcision). The entire labia minoria are stretched fro m clitoris is removed together with a very young age in the belief Rita I. M o r r i s , P h D, R N , is an Associate Professor and Chair, adjacent parts of the labia mino- that large labia enhance sexual C o m munity Health Nursing, San Diego ra and the adjacent medial por- p l e a s u re. Entrocision is another State Unive r s i t y, San Diego, CA. tions of the interior labia majo- f o rm of cutting into the vagina UROLOGIC NURSING / March 1999 / Volume 19 Number 1 13 reported among some sade had a charismatic leader in Ismalili Shia sect, adopted Islam Aborigines in Australia at the Fran Hosken who since 1973 f rom Egypt and practice FGM. t u rn of the century. has taken up this issue, lobby- Other Muslim groups in India ing the World Health do not practice FGM. In Historical Perspectives of O r ganization and numero u s Pakistan, only the Bohra tribe F G M other international agencies. practice clitoridectomy (To u b i a , Historically, mutilations She has written extensively on 1 9 9 5 ) . have been carried out on this issue and is credited for Indonesia had genital cut- infants, girls, and women, com- compiling much of what is ting operations in the past, but monly between 4 and 12 years known about the epidemiology a re no longer perf o rmed. A of age. Women who are excised of FGM around the world (Lane series of ritual clitoral cere- at a very young age do not & Rubinstein, 1996). monies persist, which include question the pro c e d u re and In the mid 1980s and ‘90s cleaning and applying sub- g r ow up not knowing any other many refugees from African stances around the clitoris, sym- way of being (Goodwin, 1994). countries brought with them a bolic cutting, or light puncture Health care professionals need s e c ret ive and little known pro b - of the clitoris. These practices to learn a great deal more than lem — female genital mutila- a re not considered genital muti- we know today about the ori- tion. This practice was con- lation (Toubia, 1995). gins of female mutilation. It is demned widely in the We s t e rn Jones (1997) identified the not possible to conclude popular and scholarly pre s s e s population at risk in the United whether there was one origin or and has led to legislation pro- States. The findings, adjusted to several independent origins. hibiting the continuance of this the total U.S. population, esti- Female slaves in ancient Rome practice in many countries. mated 271,000 females living in had one or more rings put the U.S. in 1990 who re p o r t e d t h r ough their labia majora to Estimates of Wo m e n ancestry or place of birth as a p r event their becoming pre g- with/or at Risk of FGM/FC country or region where FGM is nant. Chastity belts were Globally, FGM prevalence is practiced. About one-fourth b rought to Europe by the estimated at 130 million girls (77,000) females were girls Crusaders. Some scholars posit and women. The World Health under 18 years of age. Eleven that infibulation was practiced O r ganization, which urges the m e t ropolitan areas have an esti- in ancient Egypt and perh a p s elimination of the practice, esti- mated 45% of women and 44% originated there or perhaps in mates that 2 million girls under- girls under age of 18 years who Africa as a puberty rite and go FGM each year (Bureau of a re circumcised or are at risk. In came to Egypt by diffusion. It is Refugee Programs, 1992). all, 65% of the estimated num- generally agreed that the prac- C u r r ently, it exists in at least 28 ber of girls under 18, with or tice was widespread in the pre - African countries, some minori- potentially at risk for FGM/FC, Islamic era in Egypt, Arabia, and ties in Asia, and refugee immi- live in 35 metropolitan areas in on the Red Sea coasts (The grants in Europe, Australia, and the United States; about 72% of Minority Rights Group, 1985). North America. It should be these girls were born in the The practice of female cir- noted that the distribution with- United States. cumcision is widespread in all in a country is not uniform and Since 1990, Immigration and continents of the world. A is determined by tribal and eth- Naturalization Service (INS) data G r eek papyrus dated 163 B.C. nic divisions. Clitoridectomy is show the country of origin for made specific re f e r ence to the most common pro c e d u re by over 121,000 immigrants admit- female circumcision. Va r i o u s f a r. Infibulation predominates in ted between 1991 and 1995 to authors have documented the Somalia, Djibouti, and Northern the United States was a country practice as existing as early as Sudan, as well as in Southern in Africa where FGM/FC is prac- the 5th century B.C. originating Egypt and the coastal areas of ticed. Immigrants from Somalia in Ethiopia or Egypt. Early Ethiopia. Outside Africa it is and Sudan, countries most Romans and Arabs also adopted seen in Oman, South Ye m e n , a f fected by FGM/FC, show the practice as a mark of United Arab Emirates. marked increases of immigrants enslavement and subjugation. In Asia, clitoridectomy is to the United States. The worldwide debate on practiced in India and Pakistan the custom began in the 1970s by a small ethno-re l i g i o u s Factors that Encourage prior to which FGM was studied minority with a total population the Practice of FGM/FC in the context of cultural re l a- of a half a million.