Female Genital Mutilation (FGM) is a surgical procedure performed on the genitals of girls and women in many parts of the world. The term FGM covers a range of procedures, which are also referred to as female circumcision and introcision.

FGM is found extensively in Africa and is also indigenous to other parts of the world. The age and time at which FGM is practised differs from community to community, and can be carried out from as early as a few days after birth, to immediately after the birth of a woman's first child. One of the notable trends in global FGM today is the progressive lowering of the age at which girls undergo the practice.

Among communities that practise FGM, the procedure is a highly valued ritual, whose purpose is to mark the transition from childhood to womanhood. In these traditional societies, FGM represents part of the rites of passage or initiation ceremonies intended to impart the skills and information a woman will need to fulfil her duties as a wife and mother.

The function of this practice, whether mild or severe, is ultimately to reduce a woman's sexual desire, and so ensure her virginity until marriage. The more extensive procedure, involving stitching of the vagina, has the same aim, but reducing the size of the vagina is also intended to increase the husband's enjoyment of the sexual act.

Discussions, conducted for the purposes of this report, with women who have undergone the procedure, revealed that penetration was almost always difficult and painful, even for the man, when women had undergone the more extreme forms of FGM.

Certain communities carry out FGM for religious reasons, believing that their faith requires it; this is particularly true of Muslims who adhere to the practice. Other communities consider female genitalia to be ugly, offensive or dirty, and thus the removal of the external genitalia makes a woman more hygienic and aesthetically pleasing. Some subscribe to the notion that FGM enhances a woman's fertility, and the chances of her children's survival.

All members of communities practising FGM have a role in perpetuating it. Families of girls or women who undergo FGM support it because it makes their daughters marriageable - the operation ensures that their daughters will have ready suitors and a satisfactory bride price.

In these communities, no eligible man would consider marrying a girl who has not undergone the procedure, so FGM makes a woman culturally and socially acceptable. It is in this important way that female genital mutilation is supported and encouraged by men.

Women in the community have a role too, as it is they who arrange for and perform the operation. Typically, the procedure is arranged by the mother or grandmother and, in Africa, is usually performed by a traditional birth attendant, a midwife, or a professional circumciser.

In communities practising FGM there is literally no place for a woman who has not undergone the procedure. Such societies have sanctions, which are brought to bear on the woman and her family, ensuring that the woman's relatives enforce compliance. Other circumcised girls will no longer associate with her. She is called derogatory names, and is often denied the status and access to positions and roles that 'adult' women in that community can occupy. Ultimately, an uncircumcised woman is considered to be a child.

In traditional societies that offer women few options beyond being a wife and a mother there is great pressure to conform. Women who lack the education to seek other opportunities are doubly constrained in terms of the choices open to them. These women also typically come from communities that do not have alternatives to the traditional economy and modes of production, such as farming, fishing or pastoralism.

Even educated women from such communities are often faced with the FGM dilemma for themselves and their daughters. In Kenya, a female member of parliament (MP) had to face her earlier decision not to be circumcised when she made the choice many years later to run for public office. Her opponents used the fact that she was not circumcised to challenge her eligibility to hold a position that "only adults" could occupy. The MP's name is Linah Kilimo and today she is a minister in Kenya's National Rainbow Coalition government.

FGM in a Global Society

In the modern world few places exist in isolation, untouched by other cultures. The creation of nation states, which brought together many communities within common borders, as well as the forces of globalisation, have contributed to the blurring of boundaries in all societies.

Institutions that bring new norms in religion, national policy and legislation, and on a more individual level, education and intermarriage, create new options for societies. Sociocultural clashes arise as communities, ideas and cultures attempt to blend.

The dilemma facing people in this newly globalised world is showcased by the experience of one Senegalese couple. The woman, from a non-circumcising community, married into a society whose FGM prevalence was 70 percent. From the outset, the couple agreed that they would not circumcise their two daughters. The man's family, however, was insistent that the girls undergo the ritual and, realizing that this was no idle threat, the couple barred their daughters from visiting the man's family unescorted, lest the girls be forcefully abducted and cut, as is common when parents reject the practice. An additional, chilling threat awaited the wife - her sisters-in-law vowed that though she remained uncircumcised in life, they would circumcise her in death.

Different Forms of FGM

1. Type I (commonly referred to as clitoridectomy)

Excision (removal) of the clitoral hood, with or without removal of all or part of the clitoris.

2. Type II (commonly referred to as excision)

Excision (removal) of the clitoris, together with part or all of the labia minora (the inner vaginal lips). This is the most widely practised form.

3. Type III (commonly referred to as infibulation)

Excision (removal) of part or all of the external genitalia (clitoris, labia minora and labia majora), and stitching or narrowing of the vaginal opening, leaving a very small opening, about the size of a matchstick, to allow for the flow of urine and menstrual blood. Also known as pharaonic circumcision.

4. Type IV (Unclassified/Introcision)

Pricking, piercing or incision of the clitoris and/or labia:

• Stretching the clitoris and/or labia
• Cauterisation by burning of the clitoris and surrounding tissues
• Scraping of the vaginal orifice or cutting of the vagina
• Introduction of corrosive substances into the vagina to cause bleeding, or introduction of herbs into the vagina to tighten or narrow it
• Any other procedure that falls under the definition of female genital mutilation

Type 1 and type 2 operations account for 85 percent of all FGM. Type 3 is common in Djibouti, Somalia, Sudan and parts of Egypt, Ethiopia, Kenya, Mali, Mauritania, Niger, Nigeria, and Senegal. Type 3, also known as pharaonic circumcision, is extremely severe and involves binding a woman's legs for approximately 40 days to allow for the formation of scar tissue. Many of these communities use adhesive substances such as sugar, eggs, and even animal waste on the wound to enable it to heal.

The excisor often has to reopen the vagina to allow for easier childbirth, and then re-stitch it after birth, leaving it as small as before, or slightly larger to reduce painful intercourse. Frequently the excisor is called on a girl's wedding night to open her up so she is able to consummate her marriage.

Health complications associated with FGM

Although it is widely known that FGM can have devastating and harmful consequences for a woman throughout her life, because most communities practising it are very poor and do not have access to modern health facilities, medical emergencies arising from FGM are common, and often lead to death.
A doctor from the Fistula Hospital talks about the immediate and the long term health consequences of FGM.Credit: IRIN

It is difficult to determine the actual numbers of women who die from FGM-related complications, given the highly guarded nature of the practice. Medical record-keeping systems are also rarely configured to record FGM and FGM-related complications as causes of death.

The health problems a girl can experience are largely dependent on three factors.

First, the severity of the procedure: girls and women who undergo type II and type III are likely to experience more severe health complications, but health consequences for type I have also been widely reported.

Discussions with a doctor on the possible medical effects of type I FGM found that complications were most evident during childbirth, due to the reduced elasticity of the vagina caused by scar tissue formed as a result of the surgery. To compensate for the reduced elasticity during childbirth, tiny tears are caused around the vagina. These are too small to stitch, and end up forming more scar tissue, compromising the vagina's elasticity even further. Labour becomes longer and more painful with each subsequent birth. The tears themselves predispose the woman to infection, while her ability to experience sexual satisfaction is undermined, as the tearing leads to an ever-loosening vagina.

Second, the sanitary conditions in which the procedure is performed, and the competence of the person who performs it: most circumcisers are professionals with years of experience, but the tools and sanitary conditions of their trade are often rudimentary at best, with knife-like implements or razor blades used as the basic surgical instruments.

Close adherence to traditions that dictate what type of instrument is suitable do not allow for innovation, or the adoption of new, more suitable instruments that may be available. Typically, the circumcision ceremony takes place once a year and all eligible girls within a community are cut on the same day, using the same instrument - without the benefit of sterilisation between procedures - thus increasing the chances of infection, and the risk of exposure through such practices to HIV/AIDS.

Third, the health of the girl or woman undergoing the procedure, and her ability to heal and resist infection passed on by the procedure, is critical: if a woman is prone to infection, or has a poor immune system, she has a greater chance of becoming infected. Literally, only the strong survive.

The secret nature of FGM poses a great threat to the health of girls and women who undergo it. It is highly confidential, and outsiders are strictly prohibited from having any contact with the girls and women during and after the ceremony. Therefore, most of them have no access to a medical professional, should they need one during or after the procedure.

The 40-day isolation that characterises type III FGM, for example, means a woman might die of infection before she ever gets the chance to receive proper medical care. When qualified medical personnel perform FGM in the sanitary conditions of a hospital, the risk of infection may be reduced, but the long-term consequences remain.

Some immediate physical problems resulting from FGM are:

1. Bleeding (often haemorrhaging from rupture of the blood vessels of the clitoris), sometimes leading to death

2. Post-operative shock

3. Damage to other organs, resulting from the lack of surgical expertise of the person performing the procedure, and the aggressive resistance of the patient when anaesthesia is not used

4. Infections, including tetanus and septicaemia, through using unsterilised or poorly disinfected equipment

5. Urine retention caused by swelling and inflammation

Some longer-term consequences include:

1. Chronic infections of the bladder and vagina:
- in Type III, the urine and menstrual blood can only leave the body drop by drop
- the build-up inside the abdomen and fluid retention often cause infections and inflammation that can lead to infertility
- infections and inflammation that can lead to infertility

2. Dysmenorrhoea, or extremely painful menstruation

3. Excessive scar tissue at the site of the operation

4. Formation of cysts on the stitch line

5. Childbirth obstruction, which can result in:
- the development of fistulas
- tearing of the vaginal and/or bladder wall
- chronic incontinence

6. Risk of HIV infection. (There is a growing speculation of a potential risk of HIV/AIDS associated with the procedure, especially when the same unsterilised instruments are used on multiple girls, but this has yet to be scientifically proven.)

7. Reinfibulation must be performed each time a child is born. When infibulation (Type III) is performed, the opening left in the genital area is too small for the head of a baby to pass through. Failure to reopen this area can lead to death or brain damage of the baby, and death of the mother. The excisor must reopen the mother and re-stitch her again after the birth. In most ethnic groups the woman is re-stitched as before, leaving the same tiny opening. In other ethnic groups the opening is left slightly larger to reduce painful intercourse. (In most cases, not only must the woman be reopened for each childbirth, but also on her wedding night, when the excisor may have to be called in to open her so she can consummate the marriage.)