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Female genital mutilation
Female genital mutilation
(FGM), also known as female genital cutting and female circumcision,[a] is the ritual cutting or removal of some or all of the external female genitalia. The practice is found in Africa, Asia
Asia
and the Middle East, and within communities from countries in which FGM is common. UNICEF
UNICEF
estimated in 2016 that 200 million women living today in 30 countries—27 African countries, Indonesia, Iraqi Kurdistan
Iraqi Kurdistan
and Yemen—have undergone the procedures.[3] Typically carried out by a traditional circumciser using a blade, FGM is conducted from days after birth to puberty and beyond. In half the countries for which national figures are available, most girls are cut before the age of five.[6] Procedures differ according to the country or ethnic group. They include removal of the clitoral hood and clitoral glans; removal of the inner labia; and removal of the inner and outer labia and closure of the vulva. In this last procedure, known as infibulation, a small hole is left for the passage of urine and menstrual fluid; the vagina is opened for intercourse and opened further for childbirth.[7] The practice is rooted in gender inequality, attempts to control women's sexuality, and ideas about purity, modesty and beauty. It is usually initiated and carried out by women, who see it as a source of honour, and who fear that failing to have their daughters and granddaughters cut will expose the girls to social exclusion.[8] Health effects depend on the procedure. They can include recurrent infections, difficulty urinating and passing menstrual flow, chronic pain, the development of cysts, an inability to get pregnant, complications during childbirth, and fatal bleeding.[7] There are no known health benefits.[9] There have been international efforts since the 1970s to persuade practitioners to abandon FGM, and it has been outlawed or restricted in most of the countries in which it occurs, although the laws are poorly enforced. Since 2010 the United Nations
United Nations
has called upon healthcare providers to stop performing all forms of the procedure, including reinfibulation after childbirth and symbolic "nicking" of the clitoral hood.[10] The opposition to the practice is not without its critics, particularly among anthropologists, who have raised difficult questions about cultural relativism and the universality of human rights.[11]

Contents

1 Terminology 2 Methods 3 Classification

3.1 Variation 3.2 Types

4 Complications

4.1 Short-term and late 4.2 Pregnancy, childbirth 4.3 Psychological effects, sexual function

5 Distribution

5.1 Household surveys 5.2 Type of FGM 5.3 Prevalence 5.4 Rural areas, wealth, education 5.5 Age, ethnicity

6 Reasons

6.1 Support from women 6.2 Social obligation, poor access to information 6.3 Religion

7 History

7.1 Antiquity 7.2 Europe and the United States

8 Opposition

8.1 Colonial opposition in Kenya 8.2 Growth of opposition 8.3 United Nations 8.4 Non-practising countries

8.4.1 North America 8.4.2 Europe

9 Criticism of opposition

9.1 Tolerance versus human rights 9.2 Comparison with other procedures

10 See also 11 Notes 12 Sources

12.1 References 12.2 Works cited

13 Further reading

Terminology

Samburu FGM ceremony, Laikipia plateau, Kenya, 2004

Until the 1980s FGM was widely known in English as female circumcision, implying an equivalence in severity with male circumcision.[5] From 1929 the Kenya
Kenya
Missionary Council referred to it as the sexual mutilation of women, following the lead of Marion Scott Stevenson, a Church of Scotland
Church of Scotland
missionary.[12] References to the practice as mutilation increased throughout the 1970s.[13] In 1975 Rose Oldfield Hayes, an American anthropologist, used the term female genital mutilation in the title of a paper in American Ethnologist,[14] and four years later Fran Hosken, an Austrian-American feminist writer, called it mutilation in her influential The Hosken Report: Genital and Sexual Mutilation of Females.[15] The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children began referring to it as female genital mutilation in 1990, and the World Health Organization (WHO) followed suit in 1991.[16] Other English terms include female genital cutting (FGC) and female genital mutilation/cutting (FGM/C), preferred by those who work with practitioners.[13] In countries where FGM is common, the practice's many variants are reflected in dozens of terms, often alluding to purification.[17] In the Bambara language, spoken mostly in Mali, it is known as bolokoli ("washing your hands")[18] and in the Igbo language
Igbo language
in eastern Nigeria as isa aru or iwu aru ("having your bath").[b] A common Arabic term for purification has the root t-h-r, used for male and female circumcision (tahur and tahara).[20] It is also known in Arabic as khafḍ or khifaḍ.[21] Communities may refer to FGM as "pharaonic" for infibulation and sunna circumcision for everything else.[22] Sunna means "path or way" in Arabic and refers to the tradition of Muhammad, although none of the procedures are required within Islam.[21] The term infibulation derives from fibula, Latin for clasp; the Ancient Romans reportedly fastened clasps through the foreskins or labia of slaves to prevent sexual intercourse. The surgical infibulation of women came to be known as pharaonic circumcision in Sudan, and as Sudanese circumcision in Egypt.[23] In Somalia
Somalia
it is known simply as qodob ("to sew up").[24] Methods

Anatomy of the vulva, showing the clitoral glans, clitoral crura, corpora cavernosa, vestibular bulbs, and vaginal and urethral openings

The procedures are generally performed by a traditional circumciser (cutter or exciseuse) in the girls' homes, with or without anaesthesia. The cutter is usually an older woman, but in communities where the male barber has assumed the role of health worker he will perform FGM too.[25][c] When traditional cutters are involved, non-sterile devices are likely to be used, including knives, razors, scissors, glass, sharpened rocks and fingernails.[27] According to a nurse in Uganda, quoted in 2007 in The Lancet, a cutter would use one knife on up to 30 girls at a time.[28] Health professionals are often involved in Egypt, Kenya, Indonesia
Indonesia
and Sudan. In Egypt
Egypt
77 percent of FGM procedures, and in Indonesia
Indonesia
over 50 percent, were performed by medical professionals as of 2008 and 2016.[29][3] Women in Egypt reported in 1995 that a local anaesthetic had been used on their daughters in 60 percent of cases, a general anaesthetic in 13 percent, and neither in 25 percent (two percent were missing/don't know).[30] Classification Variation The WHO, UNICEF
UNICEF
and UNFPA issued a joint statement in 1997 defining FGM as "all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or other non-therapeutic reasons".[13] The procedures vary considerably according to ethnicity and individual practitioners. During a 1998 survey in Niger, women responded with over 50 different terms when asked what was done to them.[17] Translation problems are compounded by the women's confusion over which type of FGM they experienced, or even whether they experienced it.[31] Several studies have suggested that survey responses are unreliable. A 2003 study in Ghana
Ghana
found that in 1995 four percent said they had not undergone FGM, but in 2000 said they had, while 11 percent switched in the other direction.[32] In Tanzania in 2005, 66 percent reported FGM, but a medical exam found that 73 percent had undergone it.[33] In Sudan
Sudan
in 2006, a significant percentage of infibulated women and girls reported a less severe type.[34] Types Standard questionnaires from United Nations
United Nations
bodies ask women whether they or their daughters have undergone the following: (1) cut, no flesh removed (symbolic nicking); (2) cut, some flesh removed; (3) sewn closed; or (4) type not determined/unsure/doesn't know.[d] The most common procedures fall within the "cut, some flesh removed" category and involve complete or partial removal of the clitoral glans.[35] The World Health Organization
World Health Organization
(a UN agency) created a more detailed typology: Types I–III vary in how much tissue is removed; Type III is equivalent to the UNICEF
UNICEF
category "sewn closed"; and Type IV describes miscellaneous procedures, including symbolic nicking.[36]

Type I is "partial or total removal of the clitoris and/or the prepuce". Type Ia[e] involves removal of the clitoral hood only. This is rarely performed alone.[f] The more common procedure is Type Ib (clitoridectomy), the complete or partial removal of the clitoral glans (the visible tip of the clitoris) and clitoral hood.[1][39] The circumciser pulls the clitoral glans with her thumb and index finger and cuts it off.[g] Type II (excision) is the complete or partial removal of the inner labia, with or without removal of the clitoral glans and outer labia. Type IIa is removal of the inner labia; Type IIb, removal of the clitoral glans and inner labia; and Type IIc, removal of the clitoral glans, inner and outer labia. Excision in French can refer to any form of FGM.[1] Type III (infibulation or pharaonic circumcision), the "sewn closed" category, involves the removal of the external genitalia and fusion of the wound. The inner and/or outer labia are cut away, with or without removal of the clitoral glans.[h] Type III is found largely in northeast Africa, particularly Djibouti, Eritrea, Ethiopia, Somalia, and Sudan
Sudan
(although not in South Sudan). According to one 2008 estimate, over eight million women in Africa
Africa
are living with Type III FGM.[i] According to UNFPA in 2010, 20 percent of women with FGM have been infibulated.[42] In Somalia
Somalia
"[t]he child is made to squat on a stool or mat facing the circumciser at a height that offers her a good view of the parts to be handled. ... adult helpers grab and pull apart the legs of the girl. ... If available, this is the stage at which a local anaesthetic would be used":

The element of speed and surprise is vital and the circumciser immediately grabs the clitoris by pinching it between her nails aiming to amputate it with a slash. The organ is then shown to the senior female relatives of the child who will decide whether the amount that has been removed is satisfactory or whether more is to be cut off. After the clitoris has been satisfactorily amputated ... the circumciser can proceed with the total removal of the labia minora and the paring of the inner walls of the labia majora. Since the entire skin on the inner walls of the labia majora has to be removed all the way down to the perineum, this becomes a messy business. By now, the child is screaming, struggling, and bleeding profusely, which makes it difficult for the circumciser to hold with bare fingers and nails the slippery skin and parts that are to be cut or sutured together. ... Having ensured that sufficient tissue has been removed to allow the desired fusion of the skin, the circumciser pulls together the opposite sides of the labia majora, ensuring that the raw edges where the skin has been removed are well approximated. The wound is now ready to be stitched or for thorns to be applied. If a needle and thread are being used, close tight sutures will be placed to ensure that a flap of skin covers the vulva and extends from the mons veneris to the perineum, and which, after the wound heals, will form a bridge of scar tissue that will totally occlude the vaginal introitus.[43]

External images

Type IIIb (virgin) Type IIIb (sexually active)

— Swiss Medical Weekly[7]

The amputated parts might be placed in a pouch for the girl to wear.[44] A single hole of 2–3 mm is left for the passage of urine and menstrual fluid.[j] The vulva is closed with surgical thread, or agave or acacia thorns, and might be covered with a poultice of raw egg, herbs and sugar. To help the tissue bond, the girl's legs are tied together, often from hip to ankle; the bindings are usually loosened after a week and removed after two to six weeks.[45][27] If the remaining hole is too large in the view of the girl's family, the procedure is repeated.[24] The vagina is opened for sexual intercourse, for the first time either by a midwife with a knife or by the woman's husband with his penis.[46] In some areas, including Somaliland, female relatives of the bride and groom might watch the opening of the vagina to check that the girl is a virgin.[47] The woman is opened further for childbirth (defibulation or deinfibulation), and closed again afterwards (reinfibulation). Reinfibulation can involve cutting the vagina again to restore the pinhole size of the first infibulation. This might be performed before marriage, and after childbirth, divorce and widowhood.[k][48] Hanny Lightfoot-Klein interviewed hundreds of women and men in Sudan
Sudan
in the 1980s about sexual intercourse with Type III:

The penetration of the bride's infibulation takes anywhere from 3 or 4 days to several months. Some men are unable to penetrate their wives at all (in my study over 15%), and the task is often accomplished by a midwife under conditions of great secrecy, since this reflects negatively on the man's potency. Some who are unable to penetrate their wives manage to get them pregnant in spite of the infibulation, and the woman's vaginal passage is then cut open to allow birth to take place. ... Those men who do manage to penetrate their wives do so often, or perhaps always, with the help of the "little knife". This creates a tear which they gradually rip more and more until the opening is sufficient to admit the penis.[49]

Type IV is "[a]ll other harmful procedures to the female genitalia for non-medical purposes", including pricking, piercing, incising, scraping and cauterization.[1] It includes nicking of the clitoris (symbolic circumcision), burning or scarring the genitals, and introducing substances into the vagina to tighten it.[50][51] Labia stretching is also categorized as Type IV.[52] Common in southern and eastern Africa, the practice is supposed to enhance sexual pleasure for the man and add to the sense of a woman as a closed space. From the age of eight, girls are encouraged to stretch their inner labia using sticks and massage. Girls in Uganda
Uganda
are told they may have difficulty giving birth without stretched labia.[l][54] A definition of FGM from the WHO in 1995 included gishiri cutting and angurya cutting, found in Nigeria
Nigeria
and Niger. These were removed from the WHO's 2008 definition because of insufficient information about prevalence and consequences.[55] Angurya cutting is excision of the hymen, usually performed seven days after birth. Gishiri cutting involves cutting the vagina's front or back wall with a blade or penknife, performed in response to infertility, obstructed labour and other conditions. In a study by Nigerian physician Mairo Usman Mandara, over 30 percent of women with gishiri cuts were found to have vesicovaginal fistulae (holes that allow urine to seep into the vagina).[56] Complications Short-term and late FGM harms women's physical and emotional health throughout their lives.[57][58] It has no known health benefits.[9] The short-term and late complications depend on the type of FGM, whether the practitioner has had medical training, and whether they used antibiotics and sterilized or single-use surgical instruments. In the case of Type III, other factors include how small a hole was left for the passage of urine and menstrual blood, whether surgical thread was used instead of agave or acacia thorns, and whether the procedure was performed more than once (for example, to close an opening regarded as too wide or re-open one too small).[7]

FGM awareness session run by the African Union
African Union
Mission to Somalia
Somalia
at the Walalah Biylooley refugee camp, Mogadishu

Common short-term complications include swelling, excessive bleeding, pain, urine retention, and healing problems/wound infection. A 2014 systematic review of 56 studies suggested that over one in ten girls and women undergoing any form of FGM, including symbolic nicking of the clitoris (Type IV), experience immediate complications, although the risks increased with Type III. The review also suggested that there was under-reporting. efnBerg and Underland (Norwegian Knowledge Centre for the Health Services, 2014): "There was evidence of under-reporting of complications. However, the findings show that the FGM/C procedure unequivocally causes immediate, and typically several, health complications during the FGM/C procedure and the short-term period. Each of the most common complications occurred in more than one of every ten girls and women who undergo FGM/C. The participants in these studies had FGM/C types I through IV, thus immediate complications such as bleeding and swelling occur in setting with all forms of FGM/C. Even FGM/C type I and type IV 'nick', the forms of FGM/C with least anatomical extent, presented immediate complications. The results document that multiple immediate and quite serious complications can result from FGM/C. These results should be viewed in light of long-term complications, such as obstetric and gynecological problems, and protection of human rights."[59] Other short-term complications include fatal bleeding, anaemia, urinary infection, septicaemia, tetanus, gangrene, necrotizing fasciitis (flesh-eating disease), and endometritis.[60] It is not known how many girls and women die as a result of the practice, because complications may not be recognized or reported. The practitioners' use of shared instruments is thought to aid the transmission of hepatitis B, hepatitis C and HIV, although no epidemiological studies have shown this.[61] Late complications vary depending on the type of FGM.[7] They include the formation of scars and keloids that lead to strictures and obstruction, epidermoid cysts that may become infected, and neuroma formation (growth of nerve tissue) involving nerves that supplied the clitoris.[62][63] An infibulated girl may be left with an opening as small as 2–3 mm, which can cause prolonged, drop-by-drop urination, pain while urinating, and a feeling of needing to urinate all the time. Urine may collect underneath the scar, leaving the area under the skin constantly wet, which can lead to infection and the formation of small stones. The opening is larger in women who are sexually active or have given birth by vaginal delivery, but the urethra opening may still be obstructed by scar tissue. Vesicovaginal or rectovaginal fistulae can develop (holes that allow urine or faeces to seep into the vagina).[7][64] This and other damage to the urethra and bladder can lead to infections and incontinence, pain during sexual intercourse and infertility.[62] Painful periods are common because of the obstruction to the menstrual flow, and blood can stagnate in the vagina and uterus. Complete obstruction of the vagina can result in hematocolpos and hematometra (where the vagina and uterus fill with menstrual blood).[7] The swelling of the abdomen that results from the collection of fluid, together with the lack of menstruation, can lead to suspicion of pregnancy; Asma El Dareer, a Sudanese physician, reported in 1979 that a girl in Sudan
Sudan
with this condition was killed by her family.[65] Pregnancy, childbirth FGM may place women at higher risk of problems during pregnancy and childbirth, which are more common with the more extensive FGM procedures.[7] Infibulated women may try to make childbirth easier by eating less during pregnancy to reduce the baby's size.[66]:99 In women with vesicovaginal or rectovaginal fistulae, it is difficult to obtain clear urine samples as part of prenatal care, making the diagnosis of conditions such as pre-eclampsia harder.[62] Cervical evaluation during labour may be impeded and labour prolonged or obstructed. Third-degree laceration (tears), anal-sphincter damage and emergency caesarean section are more common in infibulated women.[7][66]:97 Neonatal mortality is increased. The WHO estimated in 2006 that an additional 10–20 babies die per 1,000 deliveries as a result of FGM. The estimate was based on a study conducted on 28,393 women attending delivery wards at 28 obstetric centres in Burkina Faso, Ghana, Kenya, Nigeria, Senegal
Senegal
and Sudan. In those settings all types of FGM were found to pose an increased risk of death to the baby: 15 percent higher for Type I, 32 percent for Type II, and 55 percent for Type III. The reasons for this were unclear, but may be connected to genital and urinary tract infections and the presence of scar tissue. The researchers wrote that FGM was associated with an increased risk to the mother of damage to the perineum and excessive blood loss, as well as a need to resuscitate the baby, and stillbirth, perhaps because of a long second stage of labour.[67][68] Psychological effects, sexual function According to a 2015 systematic review there is little high-quality information available on the psychological effects of FGM. Several small studies have concluded that women with FGM suffer from anxiety, depression and post-traumatic stress disorder.[61] Feelings of shame and betrayal can develop when women leave the culture that practises FGM and learn that their condition is not the norm, but within the practising culture they may view their FGM with pride, because for them it signifies beauty, respect for tradition, chastity and hygiene.[7] Studies on sexual function have also been small.[61] A 2013 meta-analysis of 15 studies involving 12,671 women from seven countries concluded that women with FGM were twice as likely to report no sexual desire and 52 percent more likely to report dyspareunia (painful sexual intercourse). One third reported reduced sexual feelings.[69][70] Distribution Household surveys

FGM in Africa, Iraqi Kurdistan
Iraqi Kurdistan
and Yemen, as of 2015 (map of Africa).[3]

Aid agencies define the prevalence of FGM as the percentage of the 15–49 age group that has exerienced it.[71] These figures are based on nationally representative household surveys known as Demographic and Health Surveys (DHS), developed by Macro International and funded mainly by the United States
United States
Agency for International Development (USAID), and Multiple Indicator Cluster Surveys (MICS) conducted with financial and technical help from UNICEF.[31] These surveys have been carried out in Africa, Asia, Latin America and elsewhere roughly every five years, since 1984 and 1995 respectively.[72] The first to ask about FGM was the 1989–1990 DHS in northern Sudan. The first publication to estimate FGM prevalence based on DHS data (in seven countries) was by Dara Carr of Macro International in 1997.[73] Type of FGM Women are asked during the surveys: "Was the genital area just nicked/cut without removing any flesh? Was any flesh (or something) removed from the genital area? Was your genital area sewn?"[74] Most women report "cut, some flesh removed" (Types I and II).[75] Type I is the most common form in Egypt,[76] and in the southern parts of Nigeria.[77] Type III (infibulation) is concentrated in northeastern Africa, particularly Djibouti, Eritrea, Somalia
Somalia
and Sudan.[41] In surveys in 2002–2006, 30 percent of cut girls in Djibouti, 38 percent in Eritrea, and 63 percent in Somalia
Somalia
had experienced Type III.[78] There is also a high prevalence of infibulation among girls in Niger
Niger
and Senegal,[79] and in 2013 it was estimated that in Nigeria
Nigeria
three percent of the 0–14 age group had been infibulated.[80] The type of procedure is often linked to ethnicity. In Eritrea, for example, a survey in 2002 found that all Hedareb girls had been infibulated, compared with two percent of the Tigrinya, most of whom fell into the "cut, no flesh removed" category.[17] Prevalence Further information: Prevalence of female genital mutilation by country

Percentage of the 15–49 group who have undergone FGM in 29 countries for which figures were available in 2016[3]

FGM is found mostly in what Gerry Mackie called an "intriguingly contiguous" zone in Africa—east to west from Somalia
Somalia
to Senegal, and north to south from Egypt
Egypt
to Tanzania.[81] Nationally representative figures are available for 27 countries in Africa, as well as Indonesia, Iraqi Kurdistan
Iraqi Kurdistan
and Yemen. Over 200 million women and girls are thought to be living with FGM in those 30 countries.[3][82] The highest concentrations among the 15–49 age group are in Somalia (98 percent), Guinea
Guinea
(97 percent), Djibouti
Djibouti
(93 percent), Egypt
Egypt
(91 percent) and Sierra Leone
Sierra Leone
(90 percent).[83] As of 2013, 27.2 million women had undergone FGM in Egypt, 23.8 million in Ethiopia, and 19.9 million in Nigeria.[84] There is also a high concentration in Indonesia, where Type I (clitoridectomy) and Type IV [symbolic nicking]) are practised. The Indonesian Ministry of Health and the Indonesian Ulema Council both say that the clitoris should not be cut. The prevalence rate for the 0–11 group in Indonesia
Indonesia
is 49 percent (13.4 million).[82]:2 Smaller studies or anecdotal reports suggest that FGM is also practised in Colombia, the Congo, Malaysia, Oman, Peru, Saudi Arabia, Sri Lanka, and the United Arab Emirates, by the Bedouin in Israel,[3][85] in Rahmah, Jordan,[86] and by the Dawoodi Bohra in India.[87] It is also found within immigrant communities around the world.[88]

Percentage of the 0–14 group who have undergone FGM in 21 countries for which figures were available as of 2016.[3]

Prevalence figures for the 15–19 age group and younger show a downward trend.[m] For example, Burkina Faso
Burkina Faso
fell from 89 percent (1980) to 58 percent (2010); Egypt
Egypt
from 97 percent (1985) to 70 percent (2015); and Kenya
Kenya
from 41 percent (1984) to 11 percent (2014).[91] From 2010 household surveys asked women about the FGM status of all their living daughters.[92] The highest concentrations among girls aged 0–14 were in Gambia
Gambia
(56 percent), Mauritania
Mauritania
(54 percent), Indonesia
Indonesia
(49 percent for 0–11) and Guinea
Guinea
(46 percent).[3] The figures suggest that a girl was one third less likely in 2014 to undergo FGM than she was 30 years ago.[93] If the rate of decline continues, the number of girls cut will nevertheless rise from 3.6 million a year in 2013 to 4.1 million in 2050 because of population growth.[n] Rural areas, wealth, education Surveys have found FGM to be more common in rural areas, less common in most countries among girls from the wealthiest homes, and (except in Sudan
Sudan
and Somalia) less common in girls whose mothers had access to primary or secondary/higher education. In Somalia
Somalia
and Sudan
Sudan
the situation was reversed: in Somalia
Somalia
the mothers' access to secondary/higher education was accompanied by a rise in prevalence of FGM in their daughters, and in Sudan
Sudan
access to any education was accompanied by a rise.[95] Age, ethnicity FGM is not invariably a rite of passage between childhood and adulthood, but is often performed on much younger children.[96] Girls are most commonly cut shortly after birth to age 15. In half the countries for which national figures were available in 2000–2010, most girls had been cut by age five.[97] Over 80 percent (of those cut) are cut before the age of five in Nigeria, Mali, Eritrea, Ghana and Mauritania.[98] The 1997 Demographic and Health Survey in Yemen found that 76 percent of girls had been cut within two weeks of birth.[99] The percentage is reversed in Somalia, Egypt, Chad
Chad
and the Central African Republic, where over 80 percent (of those cut) are cut between five and 14.[98] Just as the type of FGM is often linked to ethnicity, so is the mean age. In Kenya, for example, the Kisi cut around age 10 and the Kamba at 16.[100] A country's national prevalence often reflects a high sub-national prevalence among certain ethnicities, rather than a widespread practice.[101] In Iraq, for example, FGM is found mostly among the Kurds in Erbil
Erbil
(58 percent prevalence within age group 15–49, as of 2011), Sulaymaniyah
Sulaymaniyah
(54 percent) and Kirkuk
Kirkuk
(20 percent), giving the country a national prevalence of eight percent.[102] The practice is sometimes an ethnic marker, but it may differ along national lines. For example, in the northeastern regions of Ethiopia
Ethiopia
and Kenya, which share a border with Somalia, the Somali people
Somali people
practise FGM at around the same rate as they do in Somalia.[103] But in Guinea
Guinea
all Fulani women responding to a survey in 2012 said they had experienced FGM,[104] against 12 percent of the Fulani in Chad, while in Nigeria the Fulani are the only large ethnic group in the country not to practise it.[105] Reasons Support from women

1996 Pulitzer Prize for Feature Photography

Kenyan FGM ceremony

 — Stephanie Welsh, Newhouse News Service[106]

Dahabo Musa, a Somali woman, described infibulation in a 1988 poem as the "three feminine sorrows": the procedure itself, the wedding night when the woman is cut open, then childbirth when she is cut again.[107] Despite the evident suffering, it is women who organize all forms of FGM.[108][11] Anthropologist Rose Oldfield Hayes wrote in 1975 that educated Sudanese men who did not want their daughters to be infibulated (preferring clitoridectomy) would find the girls had been sewn up after the grandmothers arranged a visit to relatives.[109] Gerry Mackie has compared the practice to footbinding. Like FGM, footbinding was carried out on young girls, nearly universal where practised, tied to ideas about honour, chastity and appropriate marriage, and "supported and transmitted" by women.[o]

Fuambai Ahmadu
Fuambai Ahmadu
chose to undergo clitoridectomy as an adult.[111]

FGM practitioners see the procedures as marking not only ethnic boundaries but also gender difference. According to this view, male circumcision defeminizes men while FGM demasculinizes women.[112][113] Fuambai Ahmadu, an anthropologist and member of the Kono people of Sierra Leone, who in 1992 underwent clitoridectomy as an adult during a Sande society
Sande society
initiation, argued in 2000 that it is a male-centred assumption that the clitoris is important to female sexuality. African female symbolism revolves instead around the concept of the womb.[111] Infibulation
Infibulation
draws on that idea of enclosure and fertility. "[G]enital cutting completes the social definition of a child's sex by eliminating external traces of androgyny," Janice Boddy wrote in 2007. "The female body is then covered, closed, and its productive blood bound within; the male body is unveiled, opened and exposed."[114] In communities where infibulation is common, there is a preference for women's genitals to be smooth, dry and without odour, and both women and men may find the natural vulva repulsive.[115] Men seem to enjoy the effort of penetrating an infibulation.[116] The local preference for dry sex causes women to introduce substances into the vagina to reduce lubrication, including leaves, tree bark, toothpaste and Vicks menthol rub.[117] The WHO includes this practice within Type IV FGM, because the added friction during intercourse can cause lacerations and increase the risk of infection.[118] Because of the smooth appearance of an infibulated vulva, there is also a belief that infibulation increases hygiene.[119] Common reasons for FGM cited by women in surveys are social acceptance, religion, hygiene, preservation of virginity, marriageability and enhancement of male sexual pleasure.[120] In a study in northern Sudan, published in 1983, only 17.4 percent of women opposed FGM (558 out of 3,210), and most preferred excision and infibulation over clitoridectomy.[121] Attitudes are changing slowly. In Sudan
Sudan
in 2010, 42 percent of women who had heard of FGM said the practice should continue.[122] In several surveys since 2006, over 50 percent of women in Mali, Guinea, Sierra Leone, Somalia, Gambia
Gambia
and Egypt
Egypt
supported FGM's continuance, while elsewhere in Africa, Iraq
Iraq
and Yemen
Yemen
most said it should end, although in several countries only by a narrow margin.[p] Social obligation, poor access to information

Keur Simbara, Senegal, abandoned FGM in 1998 after a three-year program by Tostan.[124]

Against the argument that women willingly choose FGM for their daughters, UNICEF
UNICEF
calls the practice a "self-enforcing social convention" to which families feel they must conform to avoid uncut daughters facing social exclusion.[125] Ellen Gruenbaum reported that, in Sudan
Sudan
in the 1970s, cut girls from an Arab ethnic group would mock uncut Zabarma girls with Ya, Ghalfa! ("Hey, unclean!"). The Zabarma girls would respond Ya, mutmura! (A mutmara was a storage pit for grain that was continually opened and closed, like an infibulated woman.) But despite throwing the insult back, the Zabarma girls would ask their mothers, "What's the matter? Don't we have razor blades like the Arabs?"[126] Because of poor access to information, and because circumcisers downplay the causal connection, women may not associate the health consequences with the procedure. Lala Baldé, president of a women's association in Medina Cherif, a village in Senegal, told Mackie in 1998 that when girls fell ill or died, it was attributed to evil spirits. When informed of the causal relationship between FGM and ill health, Mackie wrote, the women broke down and wept. He argued that surveys taken before and after this sharing of information would show very different levels of support for FGM.[127] The American non-profit group Tostan, founded by Molly Melching in 1991, introduced community-empowerment programs in several countries that focus on local democracy, literacy, and education about healthcare, giving women the tools to make their own decisions.[128] In 1997, using the Tostan program, Malicounda Bambara
Malicounda Bambara
in Senegal
Senegal
became the first village to abandon FGM.[129] By 2018 over 8,000 communities in eight countries had pledged to abandon FGM and child marriage.[130] Religion Further information: Religious views on female genital mutilation Surveys have shown a widespread belief, particularly in Mali, Mauritania, Guinea
Guinea
and Egypt, that FGM is a religious requirement.[131] Gruenbaum has argued that practitioners may not distinguish between religion, tradition and chastity, making it difficult to interpret the data.[132] FGM's origins in northeastern Africa
Africa
are pre-Islamic, but the practice became associated with Islam because of that religion's focus on female chastity and seclusion.[q] There is no mention of it in the Quran.[134] It is praised in a few daʻīf (weak) hadith (sayings attributed to Muhammad) as noble but not required.[135][136] [r] In 2007 the Al-Azhar Supreme Council of Islamic Research in Cairo ruled that FGM had "no basis in core Islamic law or any of its partial provisions".[137][s] There is no mention of FGM in the Bible.[139] Christian missionaries in Africa
Africa
were among the first to object to FGM,[140] but Christian communities in Africa
Africa
do practise it. A 2013 UNICEF
UNICEF
report identified 17 African countries in which at least 10 percent of Christian women and girls aged 15 to 49 had undergone FGM; in Niger
Niger
55 percent of Christian women and girls had experienced it, compared with two percent of their Muslim counterparts.[141] The only Jewish group known to have practised it are the Beta Israel
Beta Israel
of Ethiopia. Judaism requires male circumcision, but does not allow FGM.[142] FGM is also practised by animist groups, particularly in Guinea
Guinea
and Mali.[143]

History Antiquity

Spell 1117

But if a man wants to know how to live, he should recite it [a magical spell] every day, after his flesh has been rubbed with the b3d [unknown substance] of an uncircumcised girl ['m't] and the flakes of skin [šnft] of an uncircumcised bald man.

— Inscription on Egyptian sarcophagus, c. 1991–1786 BCE[144][145]

The practice's origins are unknown, but its east-west, north-south distribution in Africa
Africa
meets in Sudan. Gerry Mackie has suggested that infibulation began there with the Meroite civilization (c. 800 BCE – c. 350 CE), before the rise of Islam, to increase confidence in paternity.[146][147] According to historian Mary Knight, Spell 1117 (c. 1991–1786 BCE) of the Ancient Egyptian Coffin Texts may refer in hieroglyphs to an uncircumcised girl ('m't):

The spell was found on the sarcophagus of Sit-hedjhotep, now in the Egyptian Museum, and dates to Egypt's Middle Kingdom.[144][t] (Paul F. O'Rourke argues that 'm't probably refers instead to a menstruating woman.)[148] The proposed circumcision of an Egyptian girl, Tathemis, is also mentioned on a Greek papyrus, from 163 BCE, in the British Museum: "Sometime after this, Nephoris [Tathemis's mother] defrauded me, being anxious that it was time for Tathemis to be circumcised, as is the custom among the Egyptians."[u] The examination of mummies has shown no evidence of FGM. Citing the Australian pathologist Grafton Elliot Smith, who examined hundreds of mummies in the early 20th century, Knight writes that the genital area may resemble Type III because during mummification the skin of the outer labia was pulled toward the anus to cover the pudendal cleft, possibly to prevent sexual violation. It was similarly not possible to determine whether Types I or II had been performed, because soft tissues had deteriorated or been removed by the embalmers.[150] The Greek geographer Strabo
Strabo
(c. 64 BCE – c. 23 CE) wrote about FGM after visiting Egypt
Egypt
around 25 BCE: "This is one of the customs most zealously pursued by them [the Egyptians]: to raise every child that is born and to circumcise [peritemnein] the males and excise [ektemnein] the females ..."[151][v][w] Philo
Philo
of Alexandria (c. 20 BCE – 50 CE) also made reference to it: "the Egyptians by the custom of their country circumcise the marriageable youth and maid in the fourteenth (year) of their age, when the male begins to get seed, and the female to have a menstrual flow."[154] It is mentioned briefly in a work attributed to the Greek physician Galen (129 – c. 200 CE): "When [the clitoris] sticks out to a great extent in their young women, Egyptians consider it appropriate to cut it out."[x] Another Greek physician, Aëtius of Amida (mid-5th to mid-6th century CE), offered more detail in book 16 of his Sixteen Books on Medicine, citing the physician Philomenes. The procedure was performed in case the clitoris, or nymphê, grew too large or triggered sexual desire when rubbing against clothing. "On this account, it seemed proper to the Egyptians to remove it before it became greatly enlarged," Aëtius wrote, "especially at that time when the girls were about to be married":

The surgery is performed in this way: Have the girl sit on a chair while a muscled young man standing behind her places his arms below the girl's thighs. Have him separate and steady her legs and whole body. Standing in front and taking hold of the clitoris with a broad-mouthed forceps in his left hand, the surgeon stretches it outward, while with the right hand, he cuts it off at the point next to the pincers of the forceps. It is proper to let a length remain from that cut off, about the size of the membrane that's between the nostrils, so as to take away the excess material only; as I have said, the part to be removed is at that point just above the pincers of the forceps. Because the clitoris is a skinlike structure and stretches out excessively, do not cut off too much, as a urinary fistula may result from cutting such large growths too deeply.[y][156]

The genital area was then cleaned with a sponge, frankincense powder and wine or cold water, and wrapped in linen bandages dipped in vinegar, until the seventh day when calamine, rose petals, date pits or a "genital powder made from baked clay" might be applied.[157] Whatever the practice's origins, infibulation became linked to slavery. Mackie cites the Portuguese missionary João dos Santos, who in 1609 wrote of a group near Mogadishu
Mogadishu
who had a "custome to sew up their Females, especially their slaves being young to make them unable for conception, which makes these slaves sell dearer, both for their chastitie, and for better confidence which their Masters put in them". Thus, Mackie argues, a "practice associated with shameful female slavery came to stand for honor".[158] Europe and the United States

Isaac Baker Brown
Isaac Baker Brown
"set to work to remove the clitoris whenever he had the opportunity of doing so".[159]

Gynaecologists in 19th-century Europe and the United States
United States
removed the clitoris to treat insanity and masturbation.[160] A British doctor, Robert Thomas, suggested clitoridectomy as a cure for nymphomania in 1813.[161][162] The first reported clitoridectomy in the West, described in The Lancet in 1825, was performed in 1822 in Berlin by Karl Ferdinand von Graefe
Karl Ferdinand von Graefe
on a 15-year-old girl who was masturbating excessively.[161][163] Isaac Baker Brown, an English gynaecologist, president of the Medical Society of London and co-founder in 1845 of St. Mary's Hospital, believed that masturbation, or "unnatural irritation" of the clitoris, caused hysteria, spinal irritation, fits, idiocy, mania and death.[163][164] He therefore "set to work to remove the clitoris whenever he had the opportunity of doing so", according to his obituary.[165] Brown performed several clitoridectomies between 1859 and 1866.[164] In the United States, J. Marion Sims
J. Marion Sims
followed Brown's work and in 1862 slit the neck of a woman's uterus and amputated her clitoris, "for the relief of the nervous or hysterical condition as recommended by Baker Brown".[166] When Brown published his views in On the Curability of Certain Forms of Insanity, Epilepsy, Catalepsy, and Hysteria in Females (1866), doctors in London accused him of quackery and expelled him from the Obstetrical Society.[167][164][168] Later in the 19th century, A. J. Bloch, a surgeon in New Orleans, removed the clitoris of a two-year-old girl who was reportedly masturbating.[169] According to a 1985 paper in the Obstetrical & Gynecological Survey, clitoridectomy was performed in the United States into the 1960s to treat hysteria, erotomania and lesbianism.[170] From the mid-1950s, James Burt, a gynaecologist in Dayton, Ohio, performed non-standard repairs of episiotomies after childbirth, adding more stitches to make the vaginal opening smaller. From 1966 until 1989, he performed "love surgery" by cutting women's pubococcygeus muscle, repositioning the vagina and urethra, and removing the clitoral hood, thereby making their genital area more appropriate, in his view, for intercourse in the missionary position.[171] "Women are structurally inadequate for intercourse," he wrote; he said he would turn them into "horny little mice".[172] In the 1960s and 1970s he performed these procedures without consent while repairing episiotomies and performing hysterectomies and other surgery; he said he had performed a variation of them on 4,000 women by 1975.[171] Following complaints, he was required in 1989 to stop practicing medicine in the United States.[173] Opposition Colonial opposition in Kenya

Further information: Campaign against female genital mutilation in colonial Kenya

Muthirigu

Little knives in their sheaths That they may fight with the church, The time has come. Elders (of the church) When Kenyatta comes You will be given women's clothes And you will have to cook him his food.

— from the Muthirigu (1929), Kikuyu dance-songs against church opposition to FGM[174]

Protestant missionaries in British East Africa
Africa
(present-day Kenya) began campaigning against FGM in the early 20th century, when Dr. John Arthur joined the Church of Scotland
Church of Scotland
Mission (CSM) in Kikuyu. An important ethnic marker, the practice was known by the Kikuyu, the country's main ethnic group, as irua for both girls and boys. It involved excision (Type II) for girls and removal of the foreskin for boys. Unexcised Kikuyu women (irugu) were outcasts.[175] Jomo Kenyatta, general secretary of the Kikuyu Central Association and later Kenya's first prime minister, wrote in 1938 that, for the Kikuyu, the institution of FGM was the "conditio sine qua non of the whole teaching of tribal law, religion and morality". No proper Kikuyu man or woman would marry or have sexual relations with someone who was not circumcised. A woman's responsibilities toward the tribe began with her initiation. Her age and place within tribal history was traced to that day, and the group of girls with whom she was cut was named according to current events, an oral tradition that allowed the Kikuyu to track people and events going back hundreds of years.[176]

Missionary Hulda Stumpf
Hulda Stumpf
(bottom left) was murdered in Kikuyu in 1930 after opposing FGM.

Beginning with the CSM mission in 1925, several missionary churches declared that FGM was prohibited for African Christians. The CSM announced that Africans practising it would be excommunicated, which resulted in hundreds leaving or being expelled.[177] The stand-off turned FGM into a focal point of the Kenyan independence movement; the 1929–1931 period is known in the country's historiography as the female circumcision controversy.[178][179] In 1929 the Kenya
Kenya
Missionary Council began referring to FGM as the "sexual mutilation of women", rather than circumcision, and a person's stance toward the practice became a test of loyalty, either to the Christian churches or to the Kikuyu Central Association.[180] Hulda Stumpf, an American missionary with the Africa
Africa
Inland Mission who opposed FGM in the girls' school she helped to run, was murdered in 1930. Edward Grigg, the governor of Kenya, told the British Colonial Office that the killer, who was never identified, had tried to circumcise her.[181][182] In 1956 the council of male elders (the Njuri Nchecke) in Meru announced a ban on FGM. Over the next three years, thousands of girls cut each other's genitals with razor blades as a symbol of defiance. The movement came to be known as Ngaitana ("I will circumcise myself"), because to avoid naming their friends the girls said they had cut themselves. Historian Lynn Thomas described the episode as significant in the history of FGM because it made clear that its victims were also its perpetrators.[183] Growth of opposition

FGM opposition

Nawal El Saadawi
Nawal El Saadawi
criticized FGM in 1972, one of the first African feminists to do so publicly.

1920s–1930s 1920s: Egyptian Doctors' Society call for ban.[A 1] 1929: Marion Scott Stevenson, Church of Scotland
Church of Scotland
missionary in Kenya, calls FGM "sexual mutilation of women." National Council of Churches of Kenya
Kenya
follow suit.[A 2] Scottish missionaries require Kikuyu Christians to take an oath against FGM; most leave to form their own churches. 1930, January: American missionary Hulda Stumpf
Hulda Stumpf
murdered in Kenya during protests about FGM.[A 3] 1930s: Religious leaders and British women lead campaign against FGM in Sudan.[A 4] 1935: Egyptian writer Salama Moussa
Salama Moussa
writes about FGM in his Ma Heia al Nahda ("What is Renaissance?").[A 5]

1940s–1960s 1946: Sudan, under Anglo-Egyptian control, bans infibulation; the law is barely enforced.[A 6] 1951, May: Egyptian medical journal, Al Doktor, issues booklet on dangers of FGM.[A 7] 1957–1958: Egyptian journalist Amina al Sa'eed and Hawwaa magazine editor Rabee' Gheith publish articles on FGM.[A 7] Late 1950s: Sudanese Women's Union campaigns against FGM in their magazine, Sawt el Maraa.[A 8] 1959: Egypt
Egypt
bans infibulation in state-run hospitals; allows partial clitoridectomy if parents request it.[A 9] UN asks the WHO to investigate FGM; WHO responds that it is not a medical issue.[A 10] 1960s: Central African Republic, Ghana
Ghana
and Guinea, after gaining independence, pass laws restricting FGM. 1969: Guinean gynaecologist Aja Tounkara Diallo Fatimata begins 28-year practice of performing fake clitoridectomies to satisfy families.[A 11]

1970s

Benoite Groult
Benoite Groult
was influential in the European campaign against FGM.

1970: Egyptian physician Nawal El Saadawi
Nawal El Saadawi
criticizes FGM in Al-Mar'a wa Al-Jins (Women and Sex).[A 12] 1972: Saadawi's The Naked Face of Women describes her own circumcision.[A 13] 1975: United Nations
United Nations
International Women's Year. American social scientist Rose Oldfield Hayes calls it "female genital mutilation" in paper on FGM in Sudan.[A 14] French writer Benoîte Groult
Benoîte Groult
calls FGM "the best kept secret in the world" in her Ainsi soit-elle.[A 15] Austrian-American feminist Fran Hosken
Fran Hosken
begins writing about FGM in Women's International Network News (WIN News). 1976–1985: UN's Decade for Women. 1976: British journalist Jill Tweedie calls FGM "ritual mutilation of the female genitalia."[A 16] 1977, March: Edna Adan Ismail
Edna Adan Ismail
of Somalia's Ministry of Health speaks against FGM to Somali Democratic Women's Organization.[A 17] 1978: American feminist Mary Daly
Mary Daly
criticizes FGM in Gyn/Ecology.[A 18] Senegalese writer Awa Thiam writes about FGM in La Parole aux Négresses (Speak out Black Sisters, 1986).[A 19] 1979: Fran Hosken
Fran Hosken
publishes The Hosken Report: Genital and Sexual Mutilation of Females, the first to estimate global figures.[A 20] UN conference, Lusaka, Zambia, calls on women's groups to mobilize against FGM.[A 21] February: WHO holds seminar, "Traditional Practices Affecting the Health of Women and Children," Khartoum, Sudan.[A 22] October: Cairo Family Planning Association holds seminar, "Bodily Mutilation of Females."[A 23] December: UN General Assembly adopts Convention on the Elimination of All Forms of Discrimination against Women.[A 24]

1980s

Gloria Steinem

1980: British writer Scilla McLean writes report on FGM for Minority Rights Group in France.[A 25] March: Robin Morgan
Robin Morgan
and Gloria Steinem
Gloria Steinem
call it "female genital mutilation" in Ms magazine.[A 26] July: African women boycott session featuring Fran Hosken
Fran Hosken
at UN's Mid-Decade Conference on Women, Copenhagen.[A 27] 1981: French Association of Anthropologists publishes statement that "a certain feminism resuscitates (today) the moralistic arrogance of yesterday's colonialism."[A 28] 1981: Lillian Passmore Sanderson publishes Against the Mutilation of Women. 1982: Sudanese physician Asma El Dareer publishes study of FGM in Sudan, Woman, Why Do You Weep? Circumcision
Circumcision
and its Consequences.[A 29] Somali writer Raqiya Haji Dualeh Abdalla publishes Sisters in Affliction: Circumcision
Circumcision
and Infibulation
Infibulation
of Women in Africa.[A 30] 1983: Efua Dorkenoo
Efua Dorkenoo
founds FORWARD in London.[A 31] 1984: Inter-African Committee on Traditional Practices founded in Dakar, Senegal, calls for an end to the practice.[A 32]

References

^ UNICEF
UNICEF
2013, p. 10. ^ James Karanja, The Missionary Movement in Colonial Kenya: The Foundation of Africa
Africa
Inland Church, Cuvillier Verlag, 2009, p. 93, n. 631. ^ Janice Boddy, Civilizing Women: British Crusades in Colonial Sudan, Princeton University Press, 2007, p. 241. ^ Boddy 2007, pp. 269–270. ^ Seham Abd el Salam, "A Comprehensive Approach for Communication about Female Genital Mutilation in Egypt," in George C. Denniston, et al (eds.), Male and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice, Springer, 1999, p. 318. ^ Boddy 2007, pp. 202, 299. ^ a b el Salam 1999, pp. 318–319; UNICEF
UNICEF
2013, p. 10. ^ Rogaia Mustafa Abusharaf, "Revisiting Feminist Discourses on Inbulation: The Hosken Report," in Shell-Duncan and Hernlund 2000, p. 165. ^ Elizabeth Heger Boyle, Female Genital Cutting: Cultural Conflict in the Global Community, Johns Hopkins University Press, 2002, pp. 92, 103. ^ Boyle 2002, p. 41. ^ "Female genital mutilation", New International, 5 June 1997. ^ Jenna Krajeski, "Rebellion", The New Yorker, 14 March 2011. ^ Nawal El Saadawi, "The Struggle to End Female Genital Mutilation," in Jennifer Browdy de Hernandez, et al, African Women Writing Resistance, University of Wisconsin Press, 2010, pp. 193, 195. ^ Oldfield Hayes 1975, p. 618. ^ Lora Wildenthal, The Language of Human Rights in West Germany, University of Pennsylvania Press, 2012, p. 146. ^ Jill Tweedie, It's Only Me, Robson Books, 1980, p. 214. ^ Raqiya D. Abdalla, "'My Grandmother Called it the Three Feminine Sorrows': The Struggle of Women Against Female Circumcision
Circumcision
in Somalia," in Abusharaf 2007, p. 201; Alexandra Topping, "Somaliland's leading lady for women's rights: 'It is time for men to step up'", The Guardian, 23 June 2014. ^ Mary Daly, Gyn/Ecology, Beacon Press, 1978, p. 156. ^ Wildenthal 2012, p. 250, n. 68. ^ UNICEF
UNICEF
2013, p. 3. ^ Gloria Steinem, Outrageous Acts and Everyday Rebellions, Henry Holt & Co, 2012 [1984], p. 324. ^ Wildenthal 2012, p. 145. ^ el Salam 1999, p. 320. ^ Elizabeth Fee, "Review of The Hosken Report", Signs, 5(4), Summer 1980 (pp. 807–809), p. 809. ^ Lynn M. Thomas, "'Ngaitana (I will circumcise myself)': Lessons from Colonial Campaigns to Ban Excision in Meru, Kenya" in Shell-Duncan and Hernlund, 2000, p. 130. ^ The International Crime of Female Genital Mutilation," Ms. magazine, March 1980. ^ Boyle 2002, p. 47. ^ Birgitte Bagnol, Esmeralda Mariano, "Politics of naming sexual practices," in Sylvia Tamale (ed.), African Sexualities: A Reader, Pambazuka Press, 2011, p. 281. ^ Thomas 2000, p. 130. ^ Abdalla 2007, p. 202. ^ Wildenthal 2012, p.. 250, n.. 71. ^ Anika Rahman and Nahid Toubia, Female Genital Mutilation: A Guide to Laws and Policies Worldwide, Zed Books, 2000, p. 10.

v t e

The first known non-colonial campaign against FGM began in Egypt
Egypt
in the 1920s, when the Egyptian Doctors' Society called for a ban.[184] There was a parallel campaign in Sudan, run by religious leaders and British women. Infibulation
Infibulation
was banned there in 1946, but the law was unpopular and barely enforced.[185][z] The Egyptian government banned infibulation in state-run hospitals in 1959, but allowed partial clitoridectomy if parents requested it.[187] ( Egypt
Egypt
banned FGM entirely in 2007.) In 1959 the UN asked the WHO to investigate FGM, but the latter responded that it was not a medical matter.[188] Feminists took up the issue throughout the 1970s.[189] The Egyptian physician and feminist Nawal El Saadawi
Nawal El Saadawi
criticized FGM in her book Women and Sex (1972); the book was banned in Egypt
Egypt
and El Saadawi lost her job as director general of public health.[190] She followed up with a chapter, "The Circumcision
Circumcision
of Girls", in her book The Hidden Face of Eve: Women in the Arab World (1980), which described her own clitoridectomy when she was six years old:

I did not know what they had cut off from my body, and I did not try to find out. I just wept, and called out to my mother for help. But the worst shock of all was when I looked around and found her standing by my side. Yes, it was her, I could not be mistaken, in flesh and blood, right in the midst of these strangers, talking to them and smiling at them, as though they had not participated in slaughtering her daughter just a few moments ago.[191]

Edna Adan Ismail

In 1975 Rose Oldfield Hayes, an American social scientist, became the first female academic to publish a detailed account of FGM, aided by her ability to discuss it directly with women in Sudan. Her article in American Ethnologist called it "female genital mutilation", rather than female circumcision, and brought it to wider academic attention.[192] Edna Adan Ismail, who worked at the time for the Somalia
Somalia
Ministry of Health, discussed the health consequences of FGM in 1977 with the Somali Women's Democratic Organization.[193][194] Two years later Fran Hosken, an Austria-American feminist, published The Hosken Report: Genital and Sexual Mutilation of Females (1979),[15] the first to offer global figures. She estimated that 110,529,000 women in 20 African countries had experienced FGM.[195] The figures were speculative but consistent with later surveys.[196] Describing FGM as a "training ground for male violence", Hosken accused female practitioners of "participating in the destruction of their own kind".[197] The language caused a rift between Western and African feminists; African women boycotted a session featuring Hosken during the UN's Mid-Decade Conference on Women in Copenhagen in July 1980.[198] In 1979 the WHO held a seminar, "Traditional Practices Affecting the Health of Women and Children", in Khartoum, Sudan, and in 1981, also in Khartoum, 150 academics and activists signed a pledge to fight FGM after a workshop held by the Babiker Badri Scientific Association for Women's Studies (BBSAWS), "Female Circumcision
Circumcision
Mutilates and Endangers Women – Combat it!" Another BBSAWS workshop in 1984 invited the international community to write a joint statement for the United Nations.[199] It recommended that the "goal of all African women" should be the eradication of FGM and that, to sever the link between FGM and religion, clitoridectomy should no longer be referred to as sunna.[200] The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, founded in 1984 in Dakar, Senegal, called for an end to the practice, as did the UN's World Conference on Human Rights in Vienna in 1993. The conference listed FGM as a form of violence against women, marking it as a human-rights violation, rather than a medical issue.[201] Throughout the 1990s and 2000s governments in Africa
Africa
and the Middle East
Middle East
passed legislation banning or restricting FGM. In 2003 the African Union
African Union
ratified the Maputo Protocol on the rights of women, which supported the elimination of FGM.[202] By 2015 laws restricting FGM had been passed in at least 23 of the 27 African countries in which it is concentrated, although several fell short of a ban.[aa] United Nations In December 1993 the United Nations
United Nations
General Assembly included FGM in resolution 48/104, the Declaration on the Elimination of Violence Against Women, and from 2003 sponsored International Day of Zero Tolerance for Female Genital Mutilation, held every 6 February.[206][207] UNICEF
UNICEF
began in 2003 to promote an evidence-based social norms approach, using ideas from game theory about how communities reach decisions about FGM, and building on the work of Gerry Mackie on the demise of footbinding in China.[208] In 2005 the UNICEF
UNICEF
Innocenti Research Centre in Florence published its first report on FGM.[26] UNFPA and UNICEF
UNICEF
launched a joint program in Africa in 2007 to reduce FGM by 40 percent within the 0–15 age group and eliminate it from at least one country by 2012, goals that were not met and which they later described as unrealistic.[209][ab] In 2008 several UN bodies recognized FGM as a human-rights violation,[211] and in 2010 the UN called upon healthcare providers to stop carrying out the procedures, including reinfibulation after childbirth and symbolic nicking.[10] In 2012 the General Assembly passed resolution 67/146, "Intensifying global efforts for the elimination of female genital mutilations".[212] Non-practising countries Further information: Prevalence of female genital mutilation by country Immigration spread the practice to Australia, New Zealand, Europe and North America, all of which outlawed it entirely or restricted it to consenting adults.[213] Sweden outlawed FGM in 1982 with the Act Prohibiting the Genital Mutilation of Women, the first Western country to do so.[214] Several former colonial powers, including Belgium, Britain, France and the Netherlands, introduced new laws or made clear that it was covered by existing legislation.[215] As of 2013[update] legislation banning FGM had been passed in 33 countries outside Africa and the Middle East.[203] North America Further information: Female genital mutilation
Female genital mutilation
in the United States In the United States
United States
an estimated 513,000 women and girls had experienced FGM or were at risk as of 2012.[216][217] efnThe Centers for Disease Control's previous estimate was 168,000 as of 1990.[218] A Nigerian woman successfully contested deportation in March 1994 on the grounds that her daughters might be cut,[219] and in 1996 Fauziya Kasinga from Togo
Togo
became the first to be granted asylum to escape FGM.[220] In 1996 the Federal Prohibition of Female Genital Mutilation Act made it illegal to perform FGM on minors for non-medical reasons, and in 2013 the Transport for Female Genital Mutilation Act prohibited transporting a minor out of the country for the purpose of FGM. In addition, 24 states have legislation banning FGM.[216]:2 The American Academy of Pediatrics opposes all forms of the practice, including pricking the clitoral skin.[ac] The first FGM conviction in the US was in 2006, when Khalid Adem, who had emigrated from Ethiopia, was sentenced to ten years after severing his two-year-old daughter's clitoris with a pair of scissors.[222][ad] Canada recognized FGM as a form of persecution in July 1994, when it granted refugee status to Khadra Hassan Farah, who had fled Somalia
Somalia
to avoid her daughter being cut.[224] In 1997 section 268 of its Criminal Code was amended to ban FGM, except where "the person is at least eighteen years of age and there is no resulting bodily harm".[225][203] As of July 2017[update] there had been no prosecutions. Canadian officials have expressed concern that a few thousand Canadian girls are at risk of "vacation cutting", whereby girls are taken overseas to undergo the procedure, but as of 2017 there were no firm figures.[226] Europe Further information: Female genital mutilation
Female genital mutilation
in the United Kingdom According to the European Parliament, 500,000 women in Europe had undergone FGM as of March 2009[update].[227] France is known for its tough stance against FGM.[228] Up to 30,000 women there were thought to have experienced it as of 1995. According to Colette Gallard, a family-planning counsellor, when FGM was first encountered in France, the reaction was that Westerners ought not to intervene. It took the deaths of two girls in 1982, one of them three months old, for that attitude to change.[229][230] In 1991 a French court ruled that the Convention Relating to the Status of Refugees
Convention Relating to the Status of Refugees
offered protection to FGM victims; the decision followed an asylum application from Aminata Diop, who fled an FGM procedure in Mali.[231] The practice is outlawed by several provisions of France's penal code that address bodily harm causing permanent mutilation or torture.[232][230] All children under six who were born in France undergo medical examinations that include inspection of the genitals, and doctors are obliged to report FGM.[228] The first civil suit was in 1982,[229] and the first criminal prosecution in 1993.[224] In 1999 a woman was given an eight-year sentence for having performed FGM on 48 girls.[233] By 2014 over 100 parents and two practitioners had been prosecuted in over 40 criminal cases.[230][228] Around 137,000 women and girls living in England and Wales were born in countries where FGM is practised, as of 2011.[234] Performing FGM on children or adults was outlawed under the Prohibition of Female Circumcision
Circumcision
Act 1985.[235] This was replaced by the Female Genital Mutilation Act 2003 and Prohibition of Female Genital Mutilation (Scotland) Act 2005, which added a prohibition on arranging FGM outside the country for British citizens or permanent residents.[236][ae] The United Nations
United Nations
Committee on the Elimination of Discrimination against Women (CEDAW) asked the government in July 2013 to "ensure the full implementation of its legislation on FGM".[238] The first charges were brought in 2014 against a physician and another man; the physician had stitched an infibulated woman after opening her for childbirth. Both men were acquitted in 2015.[239] Criticism of opposition Tolerance versus human rights

Obioma Nnaemeka
Obioma Nnaemeka
criticized the renaming of female circumcision to female genital mutilation.[240]

Anthropologists have accused FGM eradicationists of cultural colonialism, and have been criticized in turn for their moral relativism and failure to defend the idea of universal human rights.[241] According to critics of the eradicationist position, the biological reductionism of the opposition to FGM, and the failure to appreciate FGM's cultural context, serves to "other" practitioners and undermine their agency—in particular when parents are referred to as "mutilators".[242] Africans who object to the tone of FGM opposition risk appearing to defend the practice. The feminist theorist Obioma Nnaemeka, herself strongly opposed to FGM, argues that renaming it female genital mutilation introduced "a subtext of barbaric African and Muslim cultures and the West's relevance (even indispensability) in purging [it]".[243] According to Ugandan law professor Sylvia Tamale, early Western opposition to FGM stemmed from a Judeo-Christian judgment that African sexual and family practices—including dry sex, polygyny, bride price and levirate marriage—required correction; African feminists "take strong exception to the imperialist, racist and dehumanising infantilization of African women".[244] Commentators highlight the appropriation of women's bodies as exhibits, such as the 1996 publication of the Pulitzer-prize-winning photographs (above) of a 16-year-old Kenyan girl undergoing FGM. The photographs were published by 12 American newspapers, without the girl consenting either to be photographed or to have the images published.[245] The debate has highlighted a tension between anthropology and feminism, with the former's focus on tolerance and the latter's on equal rights for women. According to the anthropologist Christine Walley, a common position within anti-FGM literature has been to present African women as victims of false consciousness participating in their own oppression, a position promoted by feminists in the 1970s and 1980s, including Fran Hosken, Mary Daly
Mary Daly
and Hanny Lightfoot-Klein.[246] It prompted the French Association of Anthropologists to issue a statement in 1981, at the height of the early debates, that "a certain feminism resuscitates (today) the moralistic arrogance of yesterday's colonialism."[247] Comparison with other procedures See also: Labiaplasty
Labiaplasty
§ Criticism

Martha Nussbaum: a key moral and legal issue with FGM is that it is mostly conducted on children using physical force.

Nnaemeka argues that the crucial question, broader than FGM, is why the female body is subjected to so much "abuse and indignity", including in the West.[248] Several authors have drawn a parallel between FGM and cosmetic procedures.[249] Ronán Conroy of the Royal College of Surgeons in Ireland wrote in 2006 that cosmetic genital procedures were "driving the advance" of FGM by encouraging women to see natural variations as defects.[250] Anthropologist Fadwa El Guindi compared FGM to breast enhancement, in which the maternal function of the breast becomes secondary to men's sexual pleasure.[251] Benoîte Groult made a similar point in 1975, citing FGM and cosmetic surgery as sexist and patriarchal.[252] Carla Obermeyer has argued that FGM may be conducive to a subject's social well-being in the same way that rhinoplasty and male circumcision are.[253] Despite the 2007 ban in Egypt, women there wanting FGM for their daughters seek amalyet tajmeel (cosmetic surgery) to remove what they see as excess genital tissue.[254] The WHO does not define procedures such as labiaplasty and clitoral hood reduction as FGM, but its definition aims to avoid loopholes, so several elective practices do fall within it.[255] Some legislation banning FGM, such as in Canada and the US, covers minors only, but several countries, including Sweden and the UK, have banned it regardless of consent. Sweden, for example, has banned operations "on the outer female sexual organs with a view to mutilating them or bringing about some other permanent change in them, regardless of whether or not consent has been given for the operation".[214] Gynaecologist Birgitta Essén and anthropologist Sara Johnsdotter argue that the law seems to distinguish between Western and African genitals, and deems only African women (such as those seeking reinfibulation after childbirth) unfit to make their own decisions.[256] The philosopher Martha Nussbaum
Martha Nussbaum
argues that a key concern with FGM is that it is mostly conducted on children using physical force. The distinction between social pressure and physical force is morally and legally salient, comparable to the distinction between seduction and rape. She argues further that the literacy of women in practising countries is generally poorer than in developed nations, which reduces their ability to make informed choices.[257][258] Arguments have been made that non-therapeutic male circumcision, practised by Muslims, Jews and some Christian groups, also violates children's rights. Globally about 30 percent of males over 15 are circumcised; of these, about two-thirds are Muslim.[259] An eight-member American Academy of Pediatrics
American Academy of Pediatrics
circumcision task force issued a policy statement in 2012 that the health benefits of male circumcision outweigh the risks; they recommended that it be carried out, if it is performed, by "trained and competent practitioners ... using sterile techniques and effective pain management".[260] The statement met with protests from a group of 38 doctors in Europe, who accused the task force of "cultural bias".[261] At least half the male population of the United States
United States
is circumcised,[260] while most men in Europe are not.[261] Several commentators maintain that children's rights are also violated by the genital alteration of intersex children, who are born with anomalies that physicians choose to correct.[262][263] See also

Child marriage

Notes

^ Martha Nussbaum
Martha Nussbaum
(Sex and Social Justice, 1999): "Although discussions sometimes use the terms 'female circumcision' and 'clitoridectomy', 'female genital mutilation' (FGM) is the standard generic term for all these procedures in the medical literature ... The term 'female circumcision' has been rejected by international medical practitioners because it suggests the fallacious analogy to male circumcision ..."[5] ^ For example, "a young woman must 'have her bath' before she has a baby".[19] ^ UNICEF
UNICEF
2005: "The large majority of girls and women are cut by a traditional practitioner, a category which includes local specialists (cutters or exciseuses), traditional birth attendants and, generally, older members of the community, usually women. This is true for over 80 percent of the girls who undergo the practice in Benin, Burkina Faso, Côte d'Ivoire, Eritrea, Ethiopia, Guinea, Mali, Niger, Tanzania and Yemen. In most countries, medical personnel, including doctors, nurses and certified midwives, are not widely involved in the practice."[26] ^ UNICEF
UNICEF
2013: "These categories do not fully match the WHO typology. Cut, no flesh removed describes a practice known as nicking or pricking, which currently is categorized as Type IV. Cut, some flesh removed corresponds to Type I (clitoridectomy) and Type II (excision) combined. And sewn closed corresponds to Type III, infibulation."[17] ^ One WHO report refers to Type 1a as circumcision.[37] ^ WHO, 2018: Type 1 ... the partial or total removal of the clitoris ... and in very rare cases, only the prepuce (the fold of skin surrounding the clitoris)."[9]

WHO, 2008: "[There is a] common tendency to describe Type I as removal of the prepuce, whereas this has not been documented as a traditional form of female genital mutilation. However, in some countries, medicalized female genital mutilation can include removal of the prepuce only (Type Ia) (Thabet and Thabet, 2003), but this form appears to be relatively rare (Satti et al., 2006). Almost all known forms of female genital mutilation that remove tissue from the clitoris also cut all or part of the clitoral glans itself."[38]

^ Susan Izett and Nahid Toubia (WHO, 1998): "[T]he clitoris is held between the thumb and index finger, pulled out and amputated with one stroke of a sharp object."[40] ^ WHO 2014: "Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).

"Type IIIa, removal and apposition of the labia minora; Type IIIb, removal and apposition of the labia majora."[1] ^ USAID 2008: " Infibulation
Infibulation
is practiced largely in countries located in northeastern Africa: Djibouti, Eritrea, Ethiopia, Somalia, and Sudan. ... Sudan
Sudan
alone accounts for about 3.5 million of the women. ... [T]he estimate of the total number of women infibulated in [Djibouti, Somalia, Eritrea, northern Sudan, Ethiopia, Guinea, Mali, Burkina Faso, Senegal, Chad, Nigeria, Cameroon
Cameroon
and Tanzania, for women 15–49 years old] comes to 8,245,449, or just over eight million women."[41] ^ Jasmine Abdulcadir (Swiss Medical Weekly, 2011): "In the case of infibulation, the urethral opening and part of the vaginal opening are covered by the scar. In a virgin infibulated woman the small opening left for the menstrual fluid and the urine is not wider than 2–3 mm; in sexually active women and after the delivery the vaginal opening is wider but the urethral orifice is often still covered by the scar."[7] ^ Elizabeth Kelly, Paula J. Adams Hillard (Current Opinion in Obstetrics
Obstetrics
and Gynecology, 2005): "Women commonly undergo reinfibulation after a vaginal delivery. In addition to reinfibulation, many women in Sudan
Sudan
undergo a second type of re-suturing called El-Adel, which is performed to recreate the size of the vaginal orifice to be similar to the size created at the time of primary infibulation. Two small cuts are made around the vaginal orifice to expose new tissues to suture, and then sutures are placed to tighten the vaginal orifice and perineum. This procedure, also called re-circumcision, is primarily performed after vaginal delivery, but can also be performed before marriage, after cesarean section, after divorce, and sometimes even in elderly women as a preparation before death."[27] ^ WHO 2005: "In some areas (e.g. parts of Congo and mainland Tanzania), FGM entails the pulling of the labia minora and/or clitoris over a period of about 2 to 3 weeks. The procedure is initiated by an old woman designated for this task, who puts sticks of a special type in place to hold the stretched genital parts so that they do not revert back to their original size. The girl is instructed to pull her genitalia every day, to stretch them further, and to put additional sticks in to hold the stretched parts from time to time. This pulling procedure is repeated daily for a period of about two weeks, and usually no more than four sticks are used to hold the stretched parts, as further pulling and stretching would make the genital parts unacceptably long."[53]:31 ^ UNICEF
UNICEF
2013: "The percentage of girls and women of reproductive age (15 to 49) who have experienced any form of FGM/C is the first indicator used to show how widespread the practice is in a particular country ... A second indicator of national prevalence measures the extent of cutting among daughters aged 0 to 14, as reported by their mothers. Prevalence data for girls reflect their current – not final – FGM/C status, since many of them may not have reached the customary age for cutting at the time of the survey. They are reported as being uncut but are still at risk of undergoing the procedure. Statistics for girls under age 15 therefore need to be interpreted with a high degree of caution ..."[89]

An additional complication in judging prevalence among girls is that, in countries running campaigns against FGM, women might not report that their daughters have been cut.[90] ^ UNICEF
UNICEF
2014: "If there is no reduction in the practice between now and 2050, the number of girls cut each year will grow from 3.6 million in 2013 to 6.6 million in 2050. But if the rate of progress achieved over the last 30 years is maintained, the number of girls affected annually will go from 3.6 million today to 4.1 million in 2050.

"In either scenario, the total number of girls and women cut will continue to increase due to population growth. If nothing is done, the number of girls and women affected will grow from 133 million today to 325 million in 2050. However, if the progress made so far is sustained, the number will grow from 133 million to 196 million in 2050, and almost 130 million girls will be spared this grave assault to their human rights."[94] ^ Gerry Mackie, 1996: " Footbinding
Footbinding
and infibulation correspond as follows. Both customs are nearly universal where practised; they are persistent and are practised even by those who oppose them. Both control sexual access to females and ensure female chastity and fidelity. Both are necessary for proper marriage and family honor. Both are believed to be sanctioned by tradition. Both are said to be ethnic markers, and distinct ethnic minorities may lack the practices. Both seem to have a past of contagious diffusion. Both are exaggerated over time and both increase with status. Both are supported and transmitted by women, are performed on girls about six to eight years old, and are generally not initiation rites. Both are believed to promote health and fertility. Both are defined as aesthetically pleasing compared with the natural alternative. Both are said to properly exaggerate the complementarity of the sexes, and both are claimed to make intercourse more pleasurable for the male."[110] ^ "The highest levels of support can be found in Mali, Guinea, Sierra Leone, Somalia, Gambia
Gambia
and Egypt, where more than half the female population think the practice should continue."[123] ^ Gerry Mackie, 1996: "FGM is pre-Islamic but was exaggerated by its intersection with the Islamic modesty code of family honor, female purity, virginity, chastity, fidelity, and seclusion."[133] ^ Gerry Mackie, 1996: "The Koran is silent on FGM, but several hadith (sayings attributed to Mohammed) recommend attenuating the practice for the woman's sake, praise it as noble but not commanded, or advise that female converts refrain from mutilation because even if pleasing to the husband it is painful to the wife."[134] ^ Maggie Michael, Associated Press, 2007: "[Egypt's] supreme religious authorities stressed that Islam is against female circumcision. It's prohibited, prohibited, prohibited," Grand Mufti Ali Gomaa said on the privately owned al-Mahwar network."[138] ^ Knight adds that Egyptologists are uncomfortable with the translation to uncircumcised, because there is no information about what constituted the circumcised state.[144] ^ "Sometime after this, Nephoris [Tathemis's mother] defrauded me, being anxious that it was time for Tathemis to be circumcised, as is the custom among the Egyptians. She asked that I give her 1,300 drachmae ... to clothe her ... and to provide her with a marriage dowry ... if she didn't do each of these or if she did not circumcise Tathemis in the month of Mecheir, year 18 [163 BCE], she would repay me 2,400 drachmae on the spot."[149] ^ Strabo, Geographica, c. 25 BCE: "One of the customs most zealously observed among the Aegyptians is this, that they rear every child that is born, and circumcise [περιτέμνειν, peritemnein] the males, and excise [ektemnein] the females, as is also customary among the Jews, who are also Aegyptians in origin, as I have already stated in my account of them."[152]

Book XVI, chapter 4, 16.4.9: "And then to the Harbour of Antiphilus, and, above this, to the Creophagi [meat-eaters], of whom the males have their sexual glands mutilated [kolobos] and the women are excised [ektemnein] in the Jewish fashion."

^ Knight 2001 writes that there is one extant reference from antiquity, from Xanthus of Lydia
Lydia
in the fifth century BCE, that may allude to FGM outside Egypt. Xanthus wrote, in a history of Lydia: "The Lydians arrived at such a state of delicacy that they were even the first to 'castrate' their women." Knight argues that the "castration", which is not described, may have kept women youthful, in the sense of allowing the Lydian king to have intercourse with them without pregnancy. Knight concludes that it may have been a reference to sterilization, not FGM.[153] ^ Knight adds that the attribution to Galen
Galen
is suspect.[155] ^ A paragraph break has been added for ease of reading. ^ FGM is still practised in Sudan. Some states banned it in 2008–2009, but as of 2013[update], there was no national legislation.[186] ^ For example, UNICEF
UNICEF
2013 lists Mauritania
Mauritania
as having passed legislation against FGM, but (as of that year) it was banned only from being conducted in government facilities or by medical personnel.[203]

The following are countries in which FGM is common and in which restrictions are in place as of 2013. An asterisk indicates a ban:

Benin
Benin
(2003), Burkina Faso
Burkina Faso
(1996*), Central African Republic
Central African Republic
(1966, amended 1996), Chad
Chad
(2003), Côte d'Ivoire
Côte d'Ivoire
(1998), Djibouti
Djibouti
(1995, amended 2009*), Egypt
Egypt
(2008*), Eritrea
Eritrea
(2007*), Ethiopia
Ethiopia
(2004*), Ghana
Ghana
(1994, amended 2007), Guinea
Guinea
(1965, amended 2000*), Guinea-Bissau
Guinea-Bissau
(2011*), Iraq
Iraq
(2011*), Kenya
Kenya
(2001, amended 2011*), Mauritania
Mauritania
(2005), Niger
Niger
(2003), Nigeria
Nigeria
(2015*), Senegal
Senegal
(1999*), Somalia
Somalia
(2012*), Sudan, some states (2008–2009), Tanzania (1998), Togo
Togo
(1998), Uganda
Uganda
(2010*), Yemen
Yemen
(2001*).[204][205] ^ Fifteen countries joined the program: Djibouti, Egypt, Ethiopia, Guinea, Guinea-Bissau, Kenya, Senegal
Senegal
and Sudan
Sudan
in 2008; Burkina Faso, Gambia, Uganda
Uganda
and Somalia
Somalia
in 2009; and Eritrea, Mali
Mali
and Mauritania in 2011.[210] ^ In 2010 the American Academy of Pediatrics
American Academy of Pediatrics
suggested that "pricking or incising the clitoral skin" was a harmless procedure that might satisfy parents, but it withdrew the statement after complaints.[221] ^ In 2014 President Barack Obama
Barack Obama
spoke about FGM for the first time, calling it "a tradition that's barbaric and should be eliminated".[223] ^ Female Genital Mutilation Act 2003: "A person is guilty of an offence if he excises, infibulates or otherwise mutilates the whole or any part of a girl's labia majora, labia minora or clitoris", unless "necessary for her physical or mental health". Although the legislation refers to girls, it applies to women too.[237]

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^ O'Rourke 2007, 166ff (hieroglyphs), 172 (menstruating woman). ^ Knight 2001, 329–330; Kenyon 1893. ^ Knight 2001, 331, citing G. Elliot Smith, A Contribution to the Study of Mummification in Egypt, Cairo: L'Institut Egyptien, 1906, 30, and Marc Armand Ruffer, Studies in the Paleopathology of Egypt, Chicago: University of Chicago Press, 1921, 171. ^ Strabo, Geographica, c. 25 BCE, cited in Knight 2001, 318 ^ Strabo, Geographica, Book VII, chapter 2, 17.2.5. (Cohen 2005, 59ff, argues that Strabo
Strabo
conflated the Jews with the Egyptians). ^ Knight 2001, 326. ^ Knight 2001, 333. ^ Knight 2001, 336. ^ Knight 2001, 327–328. ^ Knight 2001, 328. ^ Mackie 1996, 1003, 1009. ^ J. F. C. "Isaac Baker Brown, F.R.C.S.", Medical Times and Gazette, 8 February 1873, 155. ^ Rodriguez 2008. ^ a b Edward Shorter, From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era, New York: Simon and Schuster, 2008, 82. ^ Robert Thomas, The Modern Practice of Physick, London: Longman, Hurst, Rees, Orme, and Brown, 1813, 585–586. ^ a b Elchalal et al. 1997. ^ a b c Peter Lewis Allen, The Wages of Sin: Sex and Disease, Past and Present, Chicago: University of Chicago Press, 2000, 106. ^ J. F. C., Medical Times and Gazette, 1873, 155, cited in Allen 2000, 106. ^ Deborah Kuhn McGregor, From Midwives to Medicine: The Birth of American Gynecology, New Brunswick: Rutgers University Press, 1998, 146. ^ Black 1997. ^ Sheehan 1981. ^ John Milton Hoberman, Testosterone Dreams: Rejuvenation, Aphrodisia, Doping, Berkeley: University of California Press, 2005, 63. ^ Cutner 1985, cited in Nour 2008. Also see G. J. Barker-Benfield, The Horrors of the Half-Known Life: Male Attitudes Toward Women and Sexuality in Nineteenth-Century America, New York: Routledge, 1999, 113. ^ a b Rodriguez 2014, 149–153. ^ Wilkerson, Isabel (11 December 1988). "Charges Against Doctor Bring Ire and Questions". The New York Times. 

Donaldson James, Susan (13 December 2012). "Ohio Woman
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^ "Doctor Loses Practice Over Genital Surgery". Associated Press. 26 January 1989.  ^ Kenneth Mufuka, "Scottish Missionaries and the Circumcision Controversy in Kenya, 1900–1960", International Review of Scottish Studies, 28, 2003, 55. ^ Lynn M. Thomas,"'Ngaitana (I will circumcise myself)': Lessons from Colonial Campaigns to Ban Excision in Meru, Kenya" in Shell-Duncan and Hernlund, 2000, 132.

For irua, Jomo Kenyatta, Facing Mount Kenya, New York: Vintage Books, 1962 [1938], 129; for irugu being outcasts, Kenyatta, 127, and Zabus 2008, 48–49.

^ Kenyatta 1962 [1938], 127–130. ^ Klaus Fiedler, Christianity and African Culture, Leiden: Brill, 1996, 75. ^ Boddy 2007, 241–245. ^ Ronald Hyam, Empire and Sexuality: The British Experience, Manchester: Manchester University Press, 1990; Murray 1976, 92–104. ^ Thomas 2000, 132; for the "sexual mutilation of women", Karanja 2009, 93, n. 631.

Also see Robert Strayer, Jocelyn Murray, "The CMS and Female Circumcision", in Robert Strayer (ed.), The Making of Missionary Communities in East Africa, New York: State University of New York Press, 1978, 139ff.

^ Boddy 2007, 241, 244. ^ Dana Lee Robert, American Women in Mission: A Social History of Their Thought and Practice, Macon: Mercer University Press, 1996, 230. ^ Thomas 2000, 129–131 (131 for the girls as "central actors"); Lynn Thomas, Politics of the Womb: Women, Reproduction, and the State in Kenya, Berkeley: University of California Press, 2003, 89–91.

Also see Lynn M. Thomas, "'Ngaitana (I will circumcise myself)': The Gender and Generational Politics of the 1956 Ban on Clitoridectomy in Meru, Kenya"], Gender and History, 8(3), November 1996, 338–363. doi:10.1111/j.1468-0424.1996.tb00062.x

^ UNICEF
UNICEF
2013, 10, calls the Egyptian Doctors' Society opposition the "first known campaign" against FGM. ^ Boddy 2007, 202, 299. ^ UNICEF
UNICEF
2013, 2, 9. ^ Elizabeth Heger Boyle, Female Genital Cutting: Cultural Conflict in the Global Community, Baltimore: Johns Hopkins University Press, 2002, 92, 103. ^ Boyle 2002, 41. ^ Bagnol and Mariano 2011, 281. ^ Gruenbaum 2001, 22; Homa Khaleeli, "Nawal El Saadawi: Egypt's radical feminist", The Guardian, 15 April 2010. ^ Nawal El Saadawi, The Hidden Face of Eve, London: Zed Books, 2007 [1980], 14. ^ Hayes 1975, 21. ^ Abdalla 2007, 201. ^ Alexandra Topping, "Somaliland's leading lady for women's rights: 'It is time for men to step up'", The Guardian, 23 June 2014. ^ Yoder & Khan 2008, 2. ^ Mackie 2003, 139. ^ Hosken 1994, 5. ^ Boyle 2002, 47; Bagnol and Mariano 2011, 281. ^ Shahira Ahmed, "Babiker Badri Scientific Association for Women's Studies", in Abusharaf 2007, 176–180. ^ Ahmed 2007, 180. ^ Anika Rahman and Nahid Toubia, Female Genital Mutilation: A Guide to Laws and Policies Worldwide, New York: Zed Books, 2000, 10–11; for Vienna, UNICEF
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2013, 8. ^ Emma Bonino, "A brutal custom: Join forces to banish the mutilation of women", The New York Times, 15 September 2004; Maputo Protocol, 7–8. ^ a b c UNICEF
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2013, 8. ^ UNICEF
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2013, 8–9. ^ UNFPA– UNICEF
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Annual Report 2012, 12. ^ "48/104. Declaration on the Elimination of Violence against Women", United Nations
United Nations
General Assembly, 20 December 1993. ^ Charlotte Feldman-Jacobs, "Commemorating International Day of Zero Tolerance to Female Genital Mutilation" Archived 13 February 2010 at the Wayback Machine., Population Reference Bureau, February 2009. ^ UNICEF
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2013, 15; UNICEF
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2010. ^ UNFPA 2013, "Executive Summary", 4. ^ UNFPA 2013, Volume 1, viii. ^ WHO 2008, 8. ^ UN resolution, 20 December 2012; Emma Bonino, "Banning Female Genital Mutilation", The New York Times, 19 December 2012. ^ Australia: "Review of Australia's Female Genital Mutilation Legal Framework", Attorney General's Department, Government of Australia.

New Zealand: "Section 204A – Female genital mutilation – Crimes Act 1961", New Zealand Parliamentary Counsel Office.

Europe: "Eliminating female genital mutilation", European Commission.

United States: "18 U.S. Code § 116 – Female genital mutilation", Legal Information Institute, Cornell University Law School.

Canada: Section 268, Criminal Code, Justice Laws website, Government of Canada.

^ a b "Current situation of female genital mutilation in Sweden", European Institute for Gender Equality, European Union. ^ Boyle 2002, 97. ^ a b "Female Genital Mutilation/Cutting in the United States: Updated Estimates of Women and Girls at Risk, 2012", Centers for Disease Control and Prevention, Public Health Reports, 131, March–April 2016. ^ Julie Turkewitz, "Effects of Ancient Custom Present New Challenge to U.S. Doctors: Genital Cutting Cases Seen More as Immigration Rises", The New York Times, 6 February 2015. ^ Jones et al. 1997, 372. ^ Patricia Dysart Rudloff, "In Re: Oluloro: Risk of female genital mutilation as 'extreme hardship' in immigration proceedings", 26 Saint Mary's Law Journal, 877, 1995. ^ Celia W. Dugger, "June 9–15; Asylum From Mutilation",The New York Times, 16 June 1996.

"In re Fauziya KASINGA, file A73 476 695", U.S. Department of Justice, Executive Office for Immigration Review, decided 13 June 1996.

^ "Female Genital Mutilation", Pediatrics, 102(1), 1 July 1998, 153–156. PMID 9651425

Withdrawn policy: "Ritual Genital Cutting of Female Minors", Pediatrics, 25(5), 1 May 2010, 1088–1093. PMID 20530070 doi:10.1542/peds.2010-0187

Pam Belluck, "Group Backs Ritual 'Nick' as Female Circumcision Option", The New York Times, 6 May 2010.

^ "Man gets 10-year sentence for circumcision of 2-year-old daughter", Associated Press, 1 November 2006. ^ Nedra Pickler, "Obama To Rename Africa
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Young Leaders Program For Nelson Mandela", Huffington Post, 28 July 2014. ^ a b Clyde H. Farnsworth, "Canada Gives Somali Mother Refugee Status", The New York Times, 21 July 1994. ^ Section 268, Criminal Code of Canada. ^ Poisson, Jayme (14 July 2017). "Canadian girls are being taken abroad to undergo female genital mutilation, documents reveal". The Toronto Star. Archived from the original on 13 August 2017.  ^ Yoder, Wang & Johansen 2013, 195. ^ a b c Kool & Wahedi 2014, 3–5. ^ a b Gallard 1995, 1592. ^ a b c Megan Rowling "France reduces genital cutting with prevention, prosecutions – lawyer", Thomson Reuters Foundation, 27 September 2012. ^ Jana Meredyth Talton, "Asylum for Genital-Mutilation Fugitives: Building a Precedent", Ms., January/February 1992, 17. ^ "Current situation of female genital mutilation in France", European Institute for Gender Equality, European Union. ^ David Gollaher, Circumcision: A History of the World's Most Controversial Surgery, New York: Basic Books, 2000, 189. ^ Alison Macfarlane and Efua Dorkenoo, "Female Genital Mutilation in England and Wales", City University of London
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and Equality Now, 21 July 2014, 3.

"Country Report: United Kingdom", Study to map the current situation and trends of FGM: Country reports, European Institute for Gender Equality, Luxembourg: Publications Office of the European Union, 2013, 487–532.

For an early article on FGM in the UK, see Black & Debelle 1995

^ Kool & Wahedi 2014, 5–7; Prohibition of Female Circumcision Act 1985, legislation.gov.uk, The National Archives. ^ Female Genital Mutilation Act 2003
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and "Prohibition of Female Genital Mutilation (Scotland) Act 2005", legislation.gov.uk. ^ "Female Genital Mutilation Act 2003", legislation.gov.uk, and "Female Genital Mutilation Act 2003" (legal guidance), Crown Prosecution Service: "The Act refers to 'girls', though it also applies to women." ^ CEDAW, July 2013, 6, paras 36, 37. ^ Sandra Laville, "Doctor found not guilty of FGM on patient at London hospital", The Guardian, 4 February 2015. ^ Nnaemeka 2005, 34. ^ Eric K. Silverman, " Anthropology
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For the photographs, "Stephanie Welsh" Archived 7 October 2015 at the Wayback Machine., 1996 Pulitzer Prize winners; for other examples, Nnaemeka 2005, 30–33.

^ Walley 2002, 18, 34, 43, 60. ^ Bagnol and Mariano 2011, 281. ^ Nnaemeka 2005, 38–39. ^ Johnsdotter & Essén 2010, 32; Berer 2007, 1335. ^ Conroy 2006. ^ El Guindi 2007, 33. ^ Wildenthal 2012, 148. ^ Obermeyer 1999, 94. ^ Sara Abdel Rahim, "From Midwives to Doctors: Searching for “Safer” Circumcisions in Egypt?", The Tahrir Institute for Middle East Policy, 25 September 2014. ^ WHO 2008, 28. ^ Johnsdotter & Essén 2010, 33; Essén & Johnsdotter 2004, 32. ^ Nussbaum 1999, 123–124. ^ Also see Yael Tamir, "Hands Off Clitoridectomy" Archived 8 August 2014 at the Wayback Machine., Boston Review, Summer 1996; Martha Nussbaum, "Double Moral Standards?" Archived 8 August 2014 at the Wayback Machine., Boston Review, October/November 1996. ^ "Male circumcision: global trends and determinants of prevalence, safety and acceptability" (PDF). Geneva: World Health Organization
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American Academy of Pediatrics
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^ Nancy Ehrenreich, Mark Barr, " Intersex
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Surgery, Female Genital Cutting, and the Selective Condemnation of 'Cultural Practices'", Harvard Civil Rights-Civil Liberties Law Review, 40(1), 2005 (71–140), 74–75. ^ Gregorio, I. W. (26 April 2017). "Should Surgeons Perform Irreversible Genital Surgery
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in the new millennium". International Journal of Gynaecology and Obstetrics. 114 (1): 47–50. doi:10.1016/j.ijgo.2011.02.003. ISSN 1879-3479. PMID 21513937.  Reisel, Dan; Creighton, Sarah M. (January 2015). "Long term health consequences of Female Genital Mutilation (FGM)". Maturitas. 80 (1): 48–51. doi:10.1016/j.maturitas.2014.10.009. ISSN 1873-4111. PMID 25466303.  Rodriguez, Sarah (July 2008). "Rethinking the history of female circumcision and clitoridectomy: American medicine and female sexuality in the late nineteenth century". Journal of the History of Medicine and Allied Sciences. 63 (3): 323–347. doi:10.1093/jhmas/jrm044. ISSN 1468-4373. PMID 18065832.  Rushwan, Hamid (September 2013). "Female genital mutilation: A tragedy for women's reproductive health". African Journal of Urology. 19 (3): 130–133. doi:10.1016/j.afju.2013.03.002.  Sheehan, E. (August 1981). "Victorian clitoridectomy: Isaac Baker Brown and his harmless operative procedure". Medical Anthropology Newsletter. 12 (4): 9–15. ISSN 0543-2499. JSTOR 647794. PMID 12263443.  Shell-Duncan, Bettina (June 2008). "From Health to Human Rights: Female Genital Cutting and the Politics of Intervention". American Anthropologist. 110 (2): 225–236. doi:10.1111/j.1548-1433.2008.00028.x. JSTOR 27563985.  Toubia, Nadia F.; Sharief, E. H. (September 2003). "Female genital mutilation: have we made progress?". International Journal of Gynaecology and Obstetrics: The Official Organ of the International Federation of Gynaecology and Obstetrics. 82 (3): 251–261. ISSN 0020-7292. PMID 14499972.  Toubia, Nadia (15 September 1994). "Female Circumcision
Circumcision
as a Public Health Issue". The New England Journal of Medicine. 331 (11): 712–716. doi:10.1056/NEJM199409153311106. ISSN 0028-4793. PMID 8058079.  Wakabi, Wairagala (31 March 2007). " Africa
Africa
battles to make female genital mutilation history". Lancet. 369 (9567): 1069–1070. doi:10.1016/S0140-6736(07)60508-X. PMID 17405200.  Yasin, Berivan A.; Al-Tawil, Namir G.; Shabila, Nazar P.; Al-Hadithi, Tariq S. (8 September 2013). " Female genital mutilation
Female genital mutilation
among Iraqi Kurdish women: A cross-sectional study from Erbil
Erbil
city". BMC Public Health. 13: 809. doi:10.1186/1471-2458-13-809. ISSN 1471-2458. PMC 3844478 . PMID 24010850.  Yoder, P. Stanley; Wang, Shanxiao; Johansen, Elise (June 2013). "Estimates of female genital mutilation/cutting in 27 African countries and Yemen". Studies in Family Planning. 44 (2): 189–204. doi:10.1111/j.1728-4465.2013.00352.x. ISSN 0039-3665. PMID 23720002.  Yoder, P. Stanley; Khan, Shane (March 2008). "Numbers of women circumcised in Africa: The Production of a Total" (PDF) (39). USAID, DHS Working Papers. 

United Nations
United Nations
reports

Cappa, Claudia, et al. Female Genital Mutilation/Cutting: A Statistical Overview and Exploration of the Dynamics of Change, New York: United Nations
United Nations
Children's Fund, July 2013. Classification of female genital mutilation, Geneva: World Health Organization, 2014. "Concluding observations on the seventh periodic report of the United Kingdom of Great Britain and Northern Ireland", United Nations Committee on the Elimination of All Forms of Discrimination against Women (CEDAW), 26 July 2013 (WebCite). Diop, Nafissatou J.; Moreau, Amadou; Benga, Hélène. "Evaluation of the Long-term Impact of the TOSTAN Program on the Abandonment of FGM/C and Early Marriage: Results from a qualitative study in Senega", UNICEF, January 2008. "Djibouti", Statistical profile on female genital mutilation/cutting, UNICEF, December 2013. Eliminating Female genital mutilation: An Interagency Statement, Geneva: World Health Organization, 2008. "Eritrea", Statistical profile on female genital mutilation/cutting, UNICEF, July 2014. "Female genital mutilation", Geneva: World Health Organization, January 2018. Female Genital Mutilation/Cutting: A Global Concern, New York: United Nations Children's Fund, February 2016. Female Genital Mutilation: A Teachers' Guide, Geneva: World Health Organization, 2005. Female Genital Mutilation/Cutting: What Might the Future Hold?, New York: UNICEF, 22 July 2014. "Fresh progress toward the elimination of female genital mutilation and cutting in Egypt", UNICEF
UNICEF
press release, 2 July 2007. Global strategy to stop health-care providers from performing female genital mutilation, UNAIDS, UNDP, UNFPA, UNHCR, UNICEF, UNIFEM, WHO, FIGO, ICN, IOM, MWIA, WCPT, WMA, Geneva: World Health Organization, 2010. "Indonesia", Statistical profile on female genital mutilation/cutting, UNICEF, February 2016. "67/146. Intensifying global efforts for the elimination of female genital mutilations", United Nations
United Nations
General Assembly, adopted 20 December 2012. Izett, Susan; Toubia, Nahid. Female Genital Mutilation: An Overview, Geneva: World Health Organization, 1998. Joint Evaluation. UNFPA- UNICEF
UNICEF
Joint Program on Female Genital Mutilation/Cutting: Accelerating Change, 2008–2012, Volume 1, Volume 2, "Executive Summary", New York: UNFPA, UNICEF, September 2013. Joint Program on Female Genital Mutilation/Cutting: Accelerating Change, Annual report 2012, New York: UNFPA–UNICEF, 2012. Mackie, Gerry; LeJeune, John. "Social Dynamics of Abandonment of Harmful Practices: A New Look at the Theory", Innocenti Working Paper No. XXX, Florence: UNICEF
UNICEF
Innocenti Research Centre, 2008. Miller, Michael; Moneti, Francesca. Changing a harmful social convention: Female genital cutting/mutilation, Florence: UNICEF Innocenti Research Centre, 2005. Moneti, Francesca; Parker, David. The Dynamics of Social Change, Florence: UNICEF
UNICEF
Innocenti Research Centre, October 2010. "Nigeria", Statistical profile on female genital mutilation/cutting, UNICEF, July 2014. "Somalia", Statistical profile on female genital mutilation/cutting, UNICEF, December 2013. WHO Guidelines on the Management of Health Complications from Female Genital Mutilation, Geneva: World Health Organization, 2016. PMID 27359024

Further reading

Wikimedia Commons has media related to Female genital mutilation.

Wikiquote has quotations related to: Female genital mutilation

"Circumcision, female", The Kinsey Institute (bibliography 1960s–1980s). FGM archive, The Guardian. Haworth, Abigail. "The day I saw 248 girls suffering genital mutilation", The Observer, 18 November 2012. Lightfoot-Klein, Hanny. Prisoners of Ritual: An Odyssey Into Female Genital Circumcision
Circumcision
in Africa, New York: Routledge, 1989 Westley, David M. "Female circumcision and infibulation in Africa", Electronic Journal of Africana Bibliography, 4, 1999 (bibliography up to 1997).

Personal stories

Nawal El Saadawi, Woman
Woman
at Point Zero, London: Zed Books, 1975. Waris Dirie
Waris Dirie
and Cathleen Miller, Desert Flower, New York: William Morrow, 1998. Fauziya Kassindja and Layli Miller-Muro, Do They Hear You When You Cry, New York: Delacorte Press, 1998. Ayaan Hirsi Ali, Infidel: My Life, New York: Simon & Schuster, 2007.

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