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. 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 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). 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 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). 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 o alter GM T mat nital F , a le ge FGM fema 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. 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 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) 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 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.