Female genital mutilation

ANATOMY OR SYSTEM AFFECTED: Genitals, reproductive system

DEFINITION: The partial or complete surgical removal of the clitoris, labia minora, or labia majora (or all) for cultural reasons. Often performed without anesthesia or sterilized instruments and often performed on young females without consent or understanding.

Indications and Procedures

The various forms of female genital mutilation (FGM, also known as female genital cutting or female circumcision) have been practiced in numerous societies around the world for nearly two thousand years. Recorded evidence indicates that FGM predates the advent of both Christianity and Islam and that early Christians, Muslims, and Ethiopian Jews practiced circumcision on young girls. Historically, during the nineteenth century and until the 1940s, clitoridectomies were performed in Europe and America as a procedure to “cure” female masturbation, nervousness, and other specific types of perceived psychological dysfunction.

The United Nations Children's Fund (UNICEF) and the World Health Organization (WHO) both define female genital mutilation as "all procedures involving partial or total removal of the female external genitalia or other injury to the female genital organs for nonmedical reasons" and stated in 2024 that more than 200 million girls and women in thirty countries in Africa, Asia, and the Middle East had been subjected to the practice. The WHO and other major international organizations also define FGM as a human rights violation and actively seek its discontinuance around the world. The WHO defines four categories of FGM: partial or total removal of the clitoris (clitoridectomy) and/or the clitoral hood; partial or total removal of the clitoris and labia minora, and sometimes the labia majora; partial or total removal of the external genitalia and the fusing of the two sides, usually by suturing, to narrow the vaginal opening (infibulation); and finally, all other forms of FGM.

Certain contemporary cultures of Africa, the Middle East, and parts of Asia continue these practices. Contemporary Middle Eastern countries practicing female circumcision and genital mutilation are Iraq and Yemen. In Africa, it is concentrated in a band of countries across the north-central part of the continent, from Mauritania in the west to Somalia in the east. UNICEF estimated in 2016 that more than 80 percent of women aged 15 to 49 had undergone the procedure in Djibouti, Egypt, Eritrea, Guinea, Mali, Sierra Leone, Somalia, and Sudan. That percentage did not decline in the 2020s, despite the attention of human rights activists and the media.

In March 2024, the national parliament of the Gambia voted in favor of advancing a bill that, if enacted, would reverse the country's 2015 ban on FGM. By the following month, the bill remained in committee, and UN experts wrote a letter to Gambian legislators urging them not to pass the bill.

FGM is practiced by some immigrant populations in the United States, where it is illegal. In 2020, the Centers for Disease Control in Prevention published a study indicating that more than 513,000 women and girls in the United States had either undergone or were at risk for undergoing the procedure.

All types of female genital mutilation may create severe, long-term health effects, such as pelvic infections that can lead to infertility, chronic recurrent urinary tract infections, painful intercourse, obstetrical complications, and in some cases, surgically induced scars that can cause tearing of the tissue and even hemorrhaging during childbirth. In fact, it is not unusual for women who have been infibulated to require surgical enlargement of the vagina before their wedding night or when delivering children. Unfortunately, babies born to infibulated women may frequently suffer brain damage because of oxygen deprivation (hypoxia) caused by a prolonged and obstructed delivery. Babies may die during the painful birthing process because of a damaged birth canal. Other physical and psychological difficulties for the circumcised woman may be sexual dysfunction, delayed menarche, and genital malformation.

From a cultural perspective, there are numerous reasons or justifications given for these procedures. They are often described as rites of passage and proof of adulthood, and it is often argued that the procedures raise a woman’s status in her community because of both the added purity that circumcision brings and the bravery that initiates are called upon to demonstrate. The procedure also is believed to confer maturity and inculcate character traits regarded as positive, such as the ability to endure pain and to be submissive. In some cultures, the circumcision ritual is considered to be positive because the girl is the center of attention. She receives presents and moral instruction from her elders, creating a bond between the generations, as all women in the society must undergo the procedure; they thus share an important experience.

Furthermore, it is thought that a girl who has been circumcised will not be troubled by lustful thoughts or sensations or by physical temptations such as masturbation. Therefore, there is less risk of premarital relationships that can end in the stigma and social difficulties of illegitimate birth. The bond between husband and wife may be closer because one or both of them will never have had sex with anyone else. The relationship may be motivated by love rather than lust because there will be no physical drive for the wife, only an emotional one. There is little incentive for extramarital sex for the wife; hence, the marriage may be more secure. Children may be better cared for because the husband can be more confident that he is their father. Generally, a girl who is not circumcised is considered unclean by local villagers and, therefore, unmarriageable. In some societies, a girl who is not circumcised is believed to be dangerous, even deadly, if her clitoris touches a man’s penis.

All of these cultural arguments for female genital mutilation and female circumcision are considered by human rights organizations to be greatly outweighed by the pain and fear, the lack of consent, and the subjugation of girls and women that is inherent in the practice. The practice is also condemned because of the medical risks and the complete lack of medical necessity for them.

Female genital circumcision and female genital mutilation surgeries are almost invariably conducted in unsanitary conditions in which a midwife or close female relative uses unsterile sharp instruments, such as pieces of glass, razor blades, kitchen knives, or scissors. Not infrequently, the procedure results in tetanus, septicemia, hemorrhaging, and even shock. Human immunodeficiency virus (HIV) can be transmitted. No anesthesia is used. These procedures usually are experienced by the girl at approximately three years of age, although she may be older or younger depending upon the customs of the particular society or village.

Treatment and Therapy

There is no information regarding the surgical restoration of severed or damaged genitals. Because of severe cultural sanctions by the participating groups, which continue to hold tenaciously to such practices, female genital mutilation is seldom discussed with outsiders. Those who follow these customs do not report their occurrence. Consequently, accurate data concerning the frequency of female genital circumcision and female genital mutilation is difficult to gather.

Perspective and Prospects

Because of the high number of female genital mutilations and the deaths that this procedure has caused, it is prohibited in many Western nations, such as the United States, Great Britain, France, Sweden, and Switzerland, and in some countries of Africa, such as Egypt, Kenya, and Senegal. UNICEF and the WHO consider female genital mutilation to be a violation of human rights and recommend its eradication. In the United States, the Federal Prohibition of Female Genital Mutilation Act was passed in 1996. The Canadian Criminal Code was amended to protect children who are ordinarily residents of Canada from being removed from the country and subjected to female genital mutilation.

Female genital mutilation perpetuates patriarchal customs that seek to control female bodies and sexuality. Opponents of the practice hope that with increasing legislation and attitude changes regarding bioethical issues, fewer girls and young women will undergo these mutilating surgical procedures. One problem in this campaign is the conflict between cultural self-determination and basic human rights. Feminists, physicians, and ethicists must work respectfully with, and not independently of, local resources for cultural self-examination and change.

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