This brief contains adult content, including descriptions and diagrams of genitalia. This brief will discuss female genital cutting (FGC). Male circumcision or male genital cutting can have similar health consequences, depending on the instruments used to cut and on the method of cutting. Some ethics experts argue that male circumcision should be addressed in a similar manner to FGC. However, since the contributing factors and practices for FGC and male genital cutting are different, this brief will focus only on FGC.
Female genital cutting (FGC) is the partial or complete removal of a female’s external genitalia. Though it is practiced all over the world, FGC is particularly prevalent on the African continent. This procedure is most commonly done to girls at a young age; FGC creates negative physical health effects for the rest of their lives, and often causes trauma. Because of these negative consequences, the United Nations has officially stated that FGC violates basic human rights. However, many communities continue to practice female genital cutting for social and cultural reasons.
Women and girls are physically held down while one of the forms of FGC is performed. Depending on the extremity of the cutting, a girl will have her legs bound together anywhere from several days to several weeks in order for the wounds to grow together and close. There are multiple variations of FGC which have been categorized into four main types by the World Health Organization. See figure XXX.
These different types of female genital cutting are practiced worldwide, including in Europe and the Americas. However, FGC is predominantly practiced in Africa, in areas in the Middle East, and in areas in Asia. According to the World Health Organization (WHO), worldwide over 200 million females have undergone FGC and an estimated 3 million more are at risk of FGC every year. Over half of these women live in just three countries: Egypt, Ethiopia, and Indonesia.
Around 90% of Female Genital Cutting consists of types 1, 2 or 4 with the remaining 10% undergoing type 3. This small percentage of females that experience type 3, infibulation, is still over 8 million girls and women. In Africa alone, it is estimated that over 125 million girls and women have undergone FGC. There are 7 countries, all in Northern Africa, where over 80% of their female population (ages 15-49 years) have undergone some type of FGC. According to a 2013 report by UNICEF, Somalia has the highest percentage of women who have undergone FGC (98%), while Egypt has the largest total number of women who have been cut (27.2 million).
Surveys have shown that girls are most often cut before the age of 15, but age of cutting varies from country to country. For example, Mauritanian girls on average undergo the procedure when they are 1 month old, while 52% of cut girls from the Central African Republic are cut between 10 and 14. Half of countries that practice FGC cut girls before age 5. Young girls are often ill-informed of the negative effects of FGC, making societal, parental, and peer pressures the main factors in their understanding and consent (if given) to the procedure. FGC presents a direct conflict to the child’s right to well-being and safety.
Overall, FGC in African nations seems to be on the decline, based on surveys of attitudes and prevalence estimates. The majority of people in countries with prevalence data think FGC should end. Fewer and fewer girls aged 15-19 support FGC, which suggests hope for future change (see figure_).FIGURE: % of women 15 to 19 and 45 to 49 who think FGC should continue Of the 27 African nations where FGC is most concentrated, 22 countries already have legislation against FGC. Over half of these nations adopted legislation in or after 2000. There are also many organizations aimed at ending FGC that have worked for years towards this goal. However, the practice is still far from eradication. In the four countries with highest rates of prevalence (Egypt, Guinea, Mali and Sudan), there has been little change in prevalence over time.
The earliest signs of FGC date back to the 5th century BC. After this time, there have been some reports of FGC among peoples in tropical Africa, in the Philippines, in the Amazon, in Australia, and in parts of the early Roman Empire. From the early 1800s to the 1950s, clitoridectomy (removal of the clitoris) was performed in the United States and Western Europe to “treat” for hysteria, epilepsy, mental disorders, masturbation, excessive sexual drive, and lesbianism.
In the 1920s, individual attempts to promote FGC abandonment were made by Egyptians in Egypt. Around the same time, Protestant missionaries from Scotland banned “circumcised” girls from church in Kenya. This ban was a major failure; historians think it was one cause of the rebellions against colonial rule in Kenya. Because of Western opposition to FGC, female genital cutting became linked to anti-colonial nationalism. Culturally insensitive attempts at ending FGC led to a “sense in Africa that Northern demands for abandonment of FGC were ‘based on little more than foreign cultural aggression.’” Unsuccessful attempts at ending FGC led foreign organizations to change their stances on FGC.
In the 1950s, the World Health Organization’s official view was that FGC operations were “based on social and cultural backgrounds,” and therefore WHO did not take a stand against FGC. In Egypt in the 1950s, more Egyptians began advocating for ending the practice, and the first legislation was created. By the 1970s, other African countries began early legislative efforts at ending FGC. Increasing African non-government organizations also began advocating for abandonment.
The late 1970s saw a feminist approach to FGC. Feminists coined the term “female genital mutilation.” They suggested that FGC was a “tool of patriarchy and a symbol of women’s oppression.” While this shift attracted international attention, many African women rejected this view. Some African women felt that the term “mutilation” was offensive, though many others continue to use it today. African women also pointed out that FGC was more complicated than simply a patronistic tool; women encourage and perform the practice more often than men, and many Africans call FGC “women’s business.”
By 1982, the World Health Organization (WHO) stated that FGC was a global health concern. Organizations stressed the health risks associated with FGC using various approaches, including secondary school educational programs. These programs led to the “medicalization” of FGC. Note: “Medicalization” refers to a switch towards having trained nurses, midwives, and physicians perform the operation, rather than using untrained local figures. There is no evidence that medicalization reduces the long-term health complications of FGC. Medicalized FGC gives the impression that FGC is acceptable because it is performed by health professionals, making it harder to abandon. Further, since performing FGC becomes a new source of income for health professionals, there is incentive for practitioners to continue performing FGC. While educating the public on health effects of FGC is important, focusing solely on the health aspect is not effective at abolishing the practice.
In the 1990s, FGC was reframed as an issue of human rights. The World Health Organization, the World Medical Association, and other international organizations now take the stance that FGC is a violation of human rights in any setting (even hygienic ones).
It is important to note that the reasons people undergo FGC vary widely from region to region, and even within nations. The degree to which a girl or woman consents to the operation also varies widely from community to community. The following factors are the most common reasons for continuing FGC, and any, some, or all of these factors may go into a family’s decision to have a child cut. Many of these factors are linked.
The WHO suggests that FGC prevalence data varies more according to ethnicity than according to any other demographic factor. In other words, whether a family practices FGC has more to do with their culture and ethnic identity than what country they live in or whether they are urban or rural. There are literally thousands of ethnic groups across Africa, so FGC practices and prevalence vary dramatically. In many cases, certain types of FGC are used to distinguish individuals belonging to a group from non-members or ‘outsiders’.
One Kenyan who underwent FGC as a young girl said FGC is “an important source of my social identity. It’s what links me with my mother, my grandmothers, my aunts, my female ancestors. It celebrates our history, our connection.” Female elders who have undergone FGC often perform FGC on others because they see it as essential to the identity of women and girls.
According to UNICEF, the social pressures a girl or her family feels from the community appear to be the leading cause for the continuation of this practice. Maninka women in Guinea believe that FGC is one of the three obligations they have to their daughters, along with educating them and finding them a husband. When women do not undergo the procedure they are viewed with a lower status in their communities. Thus, many parents (often mothers) decide to have their child cut out of love; FGC is performed to avoid social sanctions that the family believes would negatively affect the girl. These social sanctions can take the form of ridicule, shame, stigma, or exclusion. This choice to cut girls rather than have them face social sanctions happens even, in some cases, when the family is opposed to FGC and wishes its discontinuation.
The variety of intertwined social and cultural factors involved make it important for communities to collectively make the decision to abandon FGC. If one family makes the decision, the daughter will experience negative social sanctions (perhaps including inability to get married) which make the change less sustainable. However, if many people in the community choose to abandon the practice, the change is sustainable. This is illustrated by the continuation of the FGC despite the percentage of women who think FGC has no benefit.
Female genital cutting is not widely preached by any major religion, but many people believe that the practice is mandated by religion. Though unsupported by the major religions in the whole, FGC is supported by certain sects within world religions including Hinduism, Islam, Judaism, and Christianity. FGC is known to predate both Hinduism and Islam, and is believed to have existed as early as the 5th century BC.
Separate from entire sects that support FGC, community religious leaders also commonly teach that FGC is a religious requirement. Some local leaders teach that FGC helps girls and women become clean and pure for Islamic prayers. In four countries, at least half of women believe FGC to be mandated by religion. These communities where FGC is supported by religious leaders sometimes view attempts to eradicate the procedure as an attack on their religious practices. For this reason, it is important to be culturally sensitive when advocating for abandonment of the practice.
Islam is the most common religion in areas where FGC is practiced in Africa. However, the practice is not limited to Islam-dominant communities, but is prevalent in areas throughout Africa regardless of dominant religion. There is no mention of FGC in the Islamic holy book, the Quran. The majority of Muslims worldwide do not practice FGC.
According to international law, all have the right to participate in cultural life and have religious freedom. However, these freedoms are limited if they violate the fundamental rights and freedoms of others. For this reason, FGC is not protected as a cultural/religious right because it violates the girl’s rights to security.
FGC is also viewed in many cultures as part of the traditional female rite of passage from childhood to womanhood. Further, it is practiced in some areas in part because of cultural ideals of femininity; women are viewed as more beautiful when "unfeminine" or "male" body parts are removed. In some cultures, the man’s foreskin is considered a "feminine" body part, while the clitoris is viewed as a "masculine" body part; in order to fit physical gender expectations in these cultures, both the clitoris and foreskin are removed.
Advocates for change should note that Africa is not isolated in these ideals of beauty: many women in Europe, Australia, and the Americas choose to undergo medically unnecessary female genital cosmetic surgery to become cleaner or more feminine. WHO states that female genital cosmetic surgery common in Europe, the Americas, and Australia falls under the definition of FGC.
Often, the family has the daughter cut so she can be eligible for marriage. In many patriarchy-based African societies marriage is linked to prosperity. In some cases, a woman who has not been cut will not be able to get married at all, or if she does marry she will not be able to marry a man of social status. In certain communities in Tanzania, the bride price for women who have been cut is much higher than that for those who have not undergone the procedure. In traditional Samburu culture in Kenya, the pervasive view among women and men is that uncut women will not be able to get married. Since women are not allowed to make their own money in traditional Samburu culture, marriage is often seen as essential for a woman’s survival.
In some communities, modesty is closely connected to marriageability because it reflects a girl’s virtue and her family’s honor. In many religious and spiritual cultures, modesty focuses on women’s dress and behavioral standards. For some groups in Africa, modesty also includes practicing female genital cutting. In these groups, girls are viewed as immodest if they have not been cut.
FGC is often linked to ideals regarding women’s sexual activity. Many women and girls are cut to discourage them from having premarital or extramarital sex. Several cultures believe that removal of the clitoris reduces a woman’s libido or sex drive; thus, FGC serves as a way to promote virginity. Further, infibulation leaves a very small hole, so some women are discouraged from having sex for fear of opening the hole or being discovered for having done so. Though research is limited and does not show causality, some studies show correlation between FGC and decreased likelihood of extramarital affairs.
It is important to note that some of these factors, such as social sanctions, marriageability and sexual activity, may be connected, at least historically, to unequal gender expectations for purity and virginity. In many societies, it is culturally acceptable for men to be sexually active before marriage, while women are expected to remain sexually inactive until marriage. In the Samburu culture in Kenya, for example, even women who have been raped are seen as "unclean," and thus unmarriageable. This expectation of female virginity may play a part in FGC’s apparent requirement for social acceptance in some cultures.
Though FGC is often viewed as a tool to control female sexuality and sexual pleasure, most Africans who support FGC do not view sexuality or marriageability as the main reason FGC should continue. The expectation of female virginity remains in some areas, but in other areas attitudes have either changed or never focused on female purity. In some communities that do practice FGC, sexual activity before marriage is culturally acceptable for both men and women. In these areas, FGC is not seen as a method of controlling female purity, but continues for other reasons.
Because many communities in Africa focus less on gender and more on other factors such as ethnic identity and hygiene, many researchers are leaning away from the view that FGC is simply a patriarchal practice. In most places, women are stronger proponents of FGC than men are, and many Africans refer to FGC as "women’s business." However, it is unclear to what extent the practice originated from unequal gender expectations and beliefs, and to what extent hesitation to end FGC stems from the continuation of gender inequality. In practice, the extent that gender inequality contributes to FGC likely varies from place to place. Readers should understand that FGC’s requirement for social acceptance is not always related to gender inequality, but in some communities the practice is or was at one time connected to male dominance.
The WHO suggests that education level is correlated to prevalence of FGC; in general, women with less education are more likely to have FGC performed on their daughters. This could be because women who are less educated may be less likely to know the negative effects of the procedure. However, the WHO warns that since FGC is such a deeply held custom, FGC is prevalent even among those with higher education. Thus, increasing education alone would not eradicate female genital cutting.
In some cultures, women are viewed as cleaner when "unclean" body parts are removed. Some groups believe that infibulation (sewing genitalia closed) removes stench and is more hygienic. In some areas, uncut women are not allowed to handle food or water because they are seen as unclean. Further, some cultures view the clitoris as toxic, and believe that if the clitoris touches a baby’s head during childbirth, the child will die. In the Gambia, some women believe that women cannot deliver children if they have not been cut. Others believe that left uncut, the clitoris will continue to grow until it touches the ground. So, many communities perceive the removal of the clitoris as important for good health, although there is no scientific foundation for that perception.
Female genital cutting has both short-term and long-term effects on physical health. The procedure inflicts intense pain on the girl or woman. It causes heavy bleeding, which can lead to death from blood loss. Cutting can also result in infection, especially when done by traditional practitioners who use non-sterilized equipment. Unclean equipment may also spread diseases, including HIV. In the long-term, cut girls may experience pain going to the bathroom, in addition to pain and infection during menstruation. Many women also describe pain during sexual intercourse, decreased sexual desire or pleasure, and inability to orgasm. During pregnancy, FGC can cause prolonged labor and other complications. It can also adversely affect infant health; FGC is associated with high rates of infant resuscitation. FGC could cause one to two additional infant deaths for every 100 births by African women who have undergone FGC. FGC is associated with shorter average lifespan.
Female genital cutting also affects women and girls’ mental health. The procedure can cause trauma, since many who experience FGC are held down and don’t know why. One WHO study that compared 23 cut women with 24 uncut women from Senegal found that 90% of women felt "intense fear, helplessness, horror, and severe pain" when cut. The study also found that 80% of the women who were cut had an affective or anxiety disorder, with a high rate of PTSD, compared to only one of the uncut women. The researchers conclude that FGC is likely to cause emotional disturbances that can lead to psychiatric disorders.
FGC causes girls to miss school, and even can halt schooling altogether. The procedure requires days off of school for the extensive preparation, for the actual cutting, and during the time it takes to recover. These days off school can put a girl behind in her education. After undergoing FGC, complete withdrawal from school is also common. A girl who has been cut is in some cultures considered eligible for marriage, and so she is seen as no longer needing a formal education. This interruption of a girl’s education makes her more reliant on others and diminishes her ability to contribute to her community.
Some suggest that FGC continuation furthers gender inequality. By continuing a practice that is harmful to women, groups that practice FGC implicitly send harmful messages to girls and women. Activist Soraya Mire, a Somalia-born woman who underwent FGC, says FGC sends the message to girls that because they are female, they are defective and "in need of reconstruction."
One effect of FGC is economic loss. There is currently little causal data as to what extent economies are affected by FGC. However, qualitative research suggests far-reaching economic impact. Research indicates that education improves economic growth when education leads to improved cognitive skills. Since FGC causes many girls to quit school or work, their economic opportunities are limited, and economic growth is stunted. One uncut woman said her peers at work often had to take sick leave for menstrual complications resulting from FGC; many were subsequently demoted or fired. Further, women who undergo FGC often require more medical care, which can be a burden to national economies. One cut woman’s daughter had lifelong health complications due to the mother’s scar tissue during labor. The medical costs of this condition caused by FGC in the mother were very high. A WHO study estimates that costs related to childbirth due to FGC in six African countries totals 3.7 million dollars every year.
In 24 out of 29 African countries where FGC is practiced, FGC is prohibited by law. Legislation against FGC takes many forms. In Mauritania and Tanzania, FGC is illegal only when performed on minors (this is also the law in the United States and Canada). In most African countries, though, the practice is illegal for all ages. Adult women may not be fully able to consent for a number of reasons:
Some governments have indicated that the legislation is symbolic in nature, and will not be enforced. The motivations for symbolic legislation vary. One reason for creating symbolic legislation is in response to the 1996 US announcement that the US will only give financial aid to countries that ban FGC. In other cases, the symbolic legislation is used to strengthen anti-FGC movements by communicating a new norm without criminalizing girls or their families. For example, in Senegal, the law was suspended for two years before implementation to provide time for awareness-raising and educational activities to raise support for the law.
Research suggests that regardless of whether legislation is symbolic or not, legislation alone is ineffective in communities where there is unanimous support for FGC. For example, pre-existing (non-symbolic) anti-FGC legislation in Egypt was strengthened in 2000. A study performed in 2008 showed virtually no improvement in FGC rates, despite the new law.
However, in areas where there is debate about continuing FGC, even symbolic legislation can give strength to those who prefer to abandon the practice. For example, one study in Senegal (symbolic legislation) showed that those who were pro-abandonment or who were considering abandoning FGC had much greater fear of prosecution compared to those who wanted to continue FGC. Anecdotal evidence also suggests that legislation bolsters authority when there are conflicting norms (in this case, continuing FGC or discontinuing FGC). Researchers conclude that legislation is important for strengthening abandonment of FGC in mixed-opinion communities. Informing the public about anti-FGC legislation also is a means of communicating the new norm.
There are several challenges with legislation as a practice towards ending female genital cutting. These gaps include:
In addition to these challenges, legislation may have other negative consequences. For example, arresting a young girl’s parents for having her cut could have psychological impact on the girl. Fines on impoverished families could have severe financial impact. Further, the laws could disproportionately affect women, since women are the main initiators of FGC.
Human rights education has proved an extremely effective practice. The best practice involves conducting three-year Community Empowerment Programs (CEPs) in developing villages. The Community Empowerment Program is translated into the local language. Class material educates participants on human rights, problem solving, health, hygiene and literacy. The program is designed to allow for open conversation between participants, emphasizing respect and equality, regardless of social status. Part of the program’s content teaches the participants the negative effects of female genital cutting, forced marriage and child marriage. It is important that the organization teaches principles to the community members and then lets them initiate and make changes. The organization that pioneered this approach is called Tostan.
To speed the spread of information, Tostan utilizes the participants as educators themselves. CEP graduates are encouraged to spread the information they are taught to other individuals in their social circles, thereby reaching out to neighboring communities and educating far more people than otherwise possible. The Orchid Project also conducts a variation of this practice in Tanzania and Kenya. The Orchid Project holds 5-day Knowledge Sharing Workshops for organizations already existing and working in countries, to diffuse information among organizations about impactful practices. Using a similar approach to educating communities, the Orchid Project allows NGOs to learn from each other. This variation began in 2015, so there is no impact data available.
Since its creation, Tostan has directly led to over 7,200 communities across 10 nations adopting a declaration to stop the practice of FGC. These community declarations impact 3 million people. A declaration of abandonment does not always lead to 100% abandonment in a community. However, researchers assert that declarations of abandonment are very effective in promoting change. As discussed earlier, change is much more sustainable if many community members decide to change at once. In cases where public declarations are publicised by the media, the chance that other communities are more open to change is greater.
An independent study compared 20 villages that had undergone the program with 20 similar villages that had not. The evaluation found that before the program, 7 out of 10 women wished to have their daughters cut. After the program, only 1 in 10 women who had directly participated in the program wanted to have their daughters cut. Encouragingly, among women who had not directly participated but lived in a village where the program took place, only 2 out of 10 women wanted to have their daughters cut after the program. Communities that have participated in the Community Empowerment Programs have also experienced economic improvement, increases in female leadership, higher education levels of female students, and better all-around female and child health. Research also shows that in communities that have made public declarations, uncut girls are able to marry without facing social repercussions.
A main challenge is convincing community and religious leaders of the negative effects of female genital cutting. When organizations encounter communities with leaders who support FGC and disapprove of interventions, the Community Empowerment Program attendance decreases. This makes it much more difficult to create local advocates for the stop of FGC.
Also, change takes time. Because of the sensitive nature of many of their topics, it is vital for tribal leaders and any foreign workers to respect and trust each other. This and the extended nature of the program makes anti-FGC efforts slow, despite inter-community involvement.
Some communities have switched to an alternative initiation ritual, since many cultures view FGC as the transition into womanhood. Since initiation rituals vary, this practice should be applied in culture-specific ways. One organization that advocates for this practice is Amref Health Africa, which works in Kenya and Tanzania.
The alternative ritual used in Maasai and Samburu communities in Kenya and Tanzania involves seclusion of girls. During the seclusion, mothers and teachers teach daughters about sexuality and sexual health, family life, and cultural values and traditions. The girls also receive encouragement to stay in school. Communities can celebrate the coming of age with special foods, special clothing, singing, dancing, and blessings during which village elders pour a milk and honey mixture over the girls’ heads. Further, boys can also join the ceremonies as they promise not to stigmatize uncut women.
One variation of this practice, used in Sudan, involves providing an alternative name for uncut women and girls. This nationwide government campaign focuses on associating the word "Saleema" (a girl’s name that in Arabic means whole, undamaged or complete) with FGC. This provides a way for uncut people to be viewed in a more positive light. The campaign uses media, T-shirts, posters, and other means of spreading information.
An ineffective suggested alternative practice involves anesthetized pricking of the clitoris.
The girls who undergo the alternative ritual benefit by learning about their bodies during seclusion, and bonding with other women. Amref estimated in 2016 that its alternative rites of passage program has helped over 10,500 girls avoid FGC since 2009. Amref’s work is associated with a decrease in FGC, but since there is currently no causal data, we do not yet know if the practice is directly impactful.
The Saleema campaign has promising impact. Through providing a viable alternative to cutting, the Saleema campaign opens up the discussion for abandonment in a country where the topic is normally taboo. It is associated with a decline in FGC prevalence among some groups. However, it is a relatively recent campaign, so further impact data is necessary.
There is no known impact for anesthetized pricking as an alternative practice.
This practice is only effective when there is already a significant number of people ready to abandon FGC in a given community. Thus, as a practice by itself alternative rites of passage ceremonies are ineffective.
More data is needed as to how effective the practice is in conjunction with other anti-FGC initiatives (such as CEPs).
This practice is only effective in cultures where FGC is important mainly because of its place as a rite of passage; if other factors also affect a culture’s attitude towards cutting, this practice is less effective.
The practice of pricking the clitoris is ineffective because it is still a form of violence against women. It does not address the human rights violation issues, despite fewer short-term medical complications. It may have psychological implications, though more research is required to know for sure.
A current best practice is enabling proper medical care for women and girls who have undergone FGC. This is done by training medical workers on how to care for people who have been cut. In the Gambia, an organization created an academic curriculum for health professionals with FGC treatment integrated into the various subjects. This was accepted into the standard curricula for all Nursing and Midwifery schools in the Gambia, as well as other health professional schools. The organization that created this program in the Gambia, called Foundation Wassu UAB, also offers manuals for treatment and educational leaflets in various languages. The manuals, given to each graduate in participating programs, also encourage graduates to share information. The WHO also has published guides for health professions students and teachers to learn how to treat women and girls who have been cut.
With better trained practitioners, these organizations are able to relieve some of the negative physical effects associated with the cutting. The Wassu program has spread to Tanzania. However, because there is not sufficient impact data, it is difficult to determine how many affected girls are helped.
Another practice is creating support groups and counseling opportunities for women and girls who have been cut, in order to treat their psychological needs. The only organization that provided this seems to be the Comité National Sénégalais contre les Pratiques Traditionnelles Néfastes (COSEPRAT) in Senegal. However, the founder of COSEPRAT died and it is unclear to what extent COSEPRAT’s work continues. This emotional need is overlooked in other anti-FGC organizations.
There is no impact data available for this practice. More research is needed to know how effective or ineffective it is at helping those who have been cut with their psychological issues.
Orchid project video: https://youtu.be/19fcxg75SIw
WHO page on FGC; statistics and explanation:
"Female Genital Mutilation," World Health Organization, accessed August 2017, http://www.who.int/mediacentre/factsheets/fs241/en/.
UNICEF report on FGC
Dr. Bettina Shell-Duncan Interview on FGC
UNICEF report on specific interventions in 5 countries