Female Genital Cutting: Confronting Cultural Challenges and Health Complications Across the Lifespan

Miranda A Farage; Kenneth W Miller; Ghebre E Tzeghai; Charles E Azuka; Jack D Sobel; William J Ledger

Disclosures

Women's Health. 2015;11(1):79-94. 

In This Article

Cultural Determinants

FGC is traditionally performed on young girls as an obligatory social norm to ensure an honorable and worthy womanhood. The age and manner in which procedure is performed varies. In some cultures, midwives and birth attendants perform the procedure on infants; in others, it is the purview of older female relatives or traditional circumcisers. In Egypt, traditional midwives or dayas were called upon historically, but today, medical personnel perform more than half of all procedures.[10] In most countries, girls are typically cut between the ages of 4 and 18 years, although the procedure is most often accomplished before menarche. In Egypt, for example, 80% of girls are cut between the ages of 5 and 9 years;[32] in Gambia, between the ages of 4 and 7 years;[33] in Mali, the median age is 6 years, with a range of 1–16 years;[34] in Tanzania, the median age is 10 years;[6] in Ethiopia over 80% are cut by age 11 years;[15] among Somalis, at least half are cut by age 8 years and 95% by age 12 years.[12]

In traditional societies, girls are held down with spread legs and the operation is performed without anesthesia using unsterilized knives, razorblades, scissors, cut glass or sharp stones. In Type I, the most common form, the clitoris is held between the thumb and forefinger and amputated with a single stroke. Packing the wound with bandages under pressure stops the bleeding. Trained personnel may stitch the clitoral artery. In Type II, the clitoris and labia minora may be removed with the same stroke, and the extent of cutting varies. In Type III, the clitoris, labia minora and inner surface of the labia majora are removed, and the cut surfaces of the labia majora are stitched together with thorns or glued with sticky substances to create fusion. The girl's legs will be bound for several weeks to accomplish healing, during which time female relatives attend to her. The procedure creates a hood that covers the urethra and most of the vagina, leaving a small opening for the passage of urine and menses. By contrast, in subgroups such as the Arab Bedouin tribes of southern Israel, the ritual remains culturally important but has been reduced to a clitoral nick with one or two stitches.[35]

Although attitudes are changing, FGC has been a deeply rooted societal norm and a number of cultural beliefs contribute to its significance.[14,36–37] It is a tradition and social obligation that brings honor to the girl and her family. Cutting reduces sexual drive and ensures that the girl remains chaste, marriageable and faithful. Although practiced by members of various religious traditions,[8,35] in predominantly Muslim communities it is often believed to be a religious obligation, and the vernacular term, Sunna, which also conveys the traditions of the Prophet, imbues some religious significance.[14,37] However, in recent years, government bodies and religious leaders have campaigned against the practice, particularly in its most extreme forms. Hygiene and esthetic norms also play a role. In some societies, the external genitalia are considered unclean and unsightly; the clitoris is viewed as a male appendage that must be removed or an organ that must be bled for cleansing and purification.[38] Last, FGC is a rite of passage that reinforces cultural identity and a sense of belonging.

In some societies, the procedure is secret and young girls are unaware of the event until they are taken aside by their mothers or female relatives to have the procedure done. In others, girls will be advised that a special event is about to transpire, although its details may not be fully understood. Still others are told they will be cut but reassured that although it is painful, they will recover. Cultural cues reinforce its social significance.[38] Uncut girls may not be allowed to serve tea or prepare food because they are unclean, and may be teased or ostracized by their cut peers. Well-known derogatory terms reinforce the view that remaining uncut would be shameful. In some communities, FGC is a celebratory rite of passage. In Sierra Leone, for example, FGC takes place as part of a group initiation into the Bondo Society, a secret society of women.[39] The event, run by a society leader who also performs the cutting, takes place in a private clearing in the bush, where the girls will spend days or weeks to be instructed in the norms of womanhood. Initiates are rewarded with celebrations, gifts and public recognition. Whatever the context, the procedure is initially painful and traumatic, but girls are reassured that they have been brave and strong and are now pure, beautiful and worthy.[38] Through affirmation and inclusion, cut girls develop a sense of pride, cultural identity and social acceptance. Mothers and grandmothers gain respect for having done their duty to foster an ideal young woman.

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