It is estimated that 100 to 140 million women worldwide have undergone female genital mutilation (FGM), and an additional 3 million girls are at risk of FGM every year. FGM refers to a group of practices that the World Health Organization (WHO) has classified into 4 types:

Type I

The removal of the prepuce with or without removing part of or the entire clitoris (often referred to as female circumcision)

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Type II

The removal of the prepuce, with partial or total removal of the clitoris and labia minora (more typically associated with clitoridectomies, or sometimes called “sunna”)

Type III

The removal of part or all the external genitalia as in type II, but also involving stitching together and narrowing the vaginal opening (a practice called infibulation)

Type IV

All other harmful procedures to the female genitalia for nonmedical purposes, including pricking, piercing, incising, scraping, and cauterizing the genital area

FGM is a complex issue that is steeped in tradition and cultural mores. It is tied to social and regional customs and is often ascribed to religious beliefs (eg, Islam). However, the practice precedes the Old Testament and Islam, with roots in ancient Egypt. The Quran neither sanctions nor prohibits female circumcision; however, it does specifically say that if it is to be done, “Do not cut severely as that is better for a woman and more desirable for a husband.” Female circumcisions are primarily practiced in patriarchal societies such as those in the Middle East, Africa, and parts of Asia. Some of the highest prevalence rates (over 90%) can be seen in northern Africa, in places such as Egypt, Mali, Guinea, Eritrea, and Sudan. Tradition, ethnicity, and societal constructs are the driving forces behind this practice. Among all socioeconomic variables, ethnicity is more highly correlated with FGM than religion. One only has to look at places like Niger, Nigeria, and Tanzania to confirm as much. In those areas, the greatest prevalence rates are not among Muslims but rather the Christian population. Wealth and education are also determining factors.

So what is the controversy? Some girls lose a little foreskin; no big deal, right? Not quite. It usually involves a partial or total removal of a girl’s clitoris and the removal of some or all of the labia minora. Often this procedure is performed under unsanitary conditions and without anesthetics. Of course, there is a tremendous amount of variation regarding how the procedure is done, even by a single practitioner. Typically, a midwife will perform the “circumcision,” and if the young girl is lucky, a razor blade will be used to cut away her genitalia. The unlucky ones have to suffer through a cutting performed using a piece of broken glass or worse. Afterward, they’ll soak in a bucket of water until the bleeding stops. Infection and shock are common. Some girls may bleed to death, and the ones who don’t have to live with both the physiological and psychological scars from the ordeal. Among a whole host of maladies, they may have lifelong sexual dysfunctions, difficulties in menstruation, as well as pregnancy and birthing complications.

With such obvious and well-known health problems, why is it such a common practice in some areas? The simple answer is tradition. It’s considered a purification ritual that is a rite of passage into womanhood, and as such, it is typically done before puberty. The girl has no choice in the matter and in some instances is ambushed by her family. Often, mothers and grandmothers will be present during the event, and it is the mother’s responsibility to organize it. Quite often, it is performed on multiple girls at once. The girls are laid down next to each other. Then, family members or volunteers hold them down to keep them from squirming. Blood-curdling screams can be heard, as one girl after another is left mutilated and bleeding. The level of pain is so severe that their bodies convulse involuntarily. This only leads to further suffering as they endure deeper and deeper cuts because of the convulsions. Aissa was born in Mali and her story is a common one. When asked about her experience, she recalled the horrible pain: “The pain is, well, it’s so difficult to describe… the type of pain that takes over when part of your body that has the most nerve endings in it is cut away. Only girls who have been cut will ever know what that level of pain is like. I honestly thought I was going to die, and then everything went black.” Recalling more about that day, she goes on, “After the pain, it was the screaming that I’ll never forget. It wasn’t just mine and my sister’s screams, there were so many other girls there-all being cut. I’ve never heard screams like that again and don’t think I ever will.”

In the same part of the world, the practice of infibulation, reinfibulation, or sometimes called re-circumcision is also common. This procedure is mainly done after childbirth and is supposed to return the woman’s genitalia to a state that mimics her virginity. However, this is not generally the rule. In fact, after removing part or all of the labia minor, part of the labia major and what may remain of the clitoris are also removed. The resulting new opening is often far too small for intercourse, and further complications have been noted, including fatal hemorrhaging and death during future childbirths. Again, this is an institutionalized custom in many societies. In fact, the Sudanese government has actively campaigned against re-circumcisions because of such severe negative outcomes, but it is so entrenched within the Sudanese culture that it has had little effect. In one report, they attempted to gain some insight into the minds of the Sudanese husbands and wives. Broadly speaking, their thinking can be broken down into 3 main groups. Some women have the procedure done because they want to feel normal, and their husbands feel it’s their responsibility to support their wives and suffer through any sexual dysfunctions that result (a kind of traditional male/female role). In the second group, women are caught between old-world traditions, and their husbands try to counterbalance any negative sexual aspects with additional foreplay and attention. In the third group, women feel they have little influence over traditions and leave the decision up to the husbands or elders, while the men attempt to change policy through education and laws. There is a kind of changing of the guard happening with both female circumcision and infibulation. The old-world traditions are changing with younger generations. Education and some measure of equality have been catalysts for that change.

FGM, including female circumcision, has been outlawed in the United States since 1996, and presently, 21 states have additional legislation on the books. Of course, this was not always so. In 1970s, this practice was not only legal but was promoted as beneficial. In Playgirl, Catherine Kellison wrote a pair of articles touting the sexual benefits of female circumcision. In the 1973 publication, “Circumcision for Women,” Kellison explains how she had her clitoral hood removed and boasted about it being a common procedure among her circle of friends. She did indicate experiencing minor discomfort during the healing process, but afterward, she claimed that climaxing “just happened easier.” In 1975, she wrote a follow-up article, “$100 Surgery for a Million-Dollar Sex Life.” From the early 19th century and up to 1959, medical journals promoted female circumcisions for a variety of health and sexual reasons. Even more shocking, some journals discussed preforming clitoridectomies as a means to reduce psychosis and hysteria in females.

Here in the US, we are in a continuing battle over the control of women’s bodies. What is it about female sexuality and a woman’s right to make decisions about matters affecting her own body that scares so many? Of course, this battle does not match the intensity that exists in some of the countries previously listed, but it does exist. And just as in those countries, religion and social pressure are used as a bludgeoning tool. The fight over abortion, the morning-after pill, and birth control is ongoing. A record number of Planned Parenthood clinics have been shut down. These clinics help the very poor, and in particular, poor women who can’t afford health insurance. They do a lot more than supply contraceptives or perform abortions, including cancer screenings and preventive health care, but they are constantly under fire. And now we are seeing more states trying to enact laws mandating that women have ultrasounds performed before an abortion, including the invasive transvaginal ultrasound. Waiting limits are also being put into place, and roadblocks after roadblocks are being initiated. In some states, it’s harder to see an abortion doctor than it was in the mid-1970s just after Roe v Wade.

Many people are taken aback when they read about the horror stories concerning female circumcisions in Africa. They can’t wrap their mind around how a society can allow such acts. It is changing, but change is difficult. Change will be particularly difficult in those male-dominated societies where women are essentially the property of their husbands or fathers. If we are to be that “shining city on a hill,” then we have to accept the fact that all women everywhere have the sole right to choose when it comes to their bodies. These decisions should be made without societal, political, or religious pressures being thrust upon them. FGM is a serious issue with horrible consequences and it should be outlawed everywhere; however, some of the very same people who condemn it and call it barbaric take no issue with inserting a cold probe into a woman’s vagina against her wishes, or denying her access to basic reproductive health care.


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