CIRCUMCISION, FEMALE

Female circumcision is the term used to identify the practice of removing healthy normal female genitalia by surgical operation. Because of the severity of the operation and its known harmful effects, the term female genital mutilation is now generally used. There are three increasingly severe types of this operation, and each makes orgasm impossible. Clitoridectomy, or sunna (Type 1), is the removal of the prepuce of the clitoris and the clitoris itself (Figure 1–1). When excited, the clitoris swells and becomes erect, and it is this excitement that causes female orgasms. Excision, or reduction (Type 2), is the removal of the prepuce, the clitoris, and the labia minora, leaving the majora intact. The labia minora produce secretions that lubricate the inner folds of the lips and prevent soreness when these lips rub against each other (Figure 1–2). Infibulation, or pharaonic circumcision (Type 3), is the removal of the prepuce, the clitoris, the labia minora and majora, and the suturing of the two sides of the vulva, leaving a very small opening for the passage of urine and menstrual blood (Figure 1–3). This type of circumcision is referred to as pharaonic probably because it is identified with circumcision methods of ancient Egypt under the pharaohs.

In a study of the various types of circumcision under-gone by women in Sierra Leone (Koso-Thomas), it was found that 39.03 percent of the women had undergone Type 1, 59.85 percent, Type 2, and 1.12 percent, Type 3. In Somalia, 80 percent of the operations are Type 3 (El Dareer). The prevalence of circumcision in Africa ranges from 10 percent in Tanzania to 98 percent in Djibouti (Toubia).

The most common and basic procedure followed during circumcision is the traditional method. In this method, usually employed by circumcisers who have no medical training, the female is firmly held down on dry ground with her legs wide apart to expose the genitalia and the parts to be removed. In some cases, the genital part to be excised is held with a special hemostatic leaf before excision, or the candidates are made to lie near a cold flowing stream so the excised area can be bathed in chilled water to numb the pain. The implements used are often unsterilized razor blades, knives, scissors, broken bottles, or any other sharp implement. Some form of herbal dressing is applied to the raw wound after the operation. The same implement is used for successive operations without sterilization. When the operation is carried out in modern clinics, standard modern surgical practice is followed.

Origin of the Practice

We do not know with any precision when, why, and how female circumcision began. There is evidence that female circumcision and female genital surgery have been done in many parts of the world, although currently it is mainly done in different communities in parts of Africa, Asia, the Far East, Europe, and South America.

The early Romans, concerned about the consequences of sexual activity among female slaves, adopted the technique of slipping rings through their labia majora (Figure 1–4) to block access to the vagina. In the twelfth century C.E., Crusaders introduced the chastity belt in Europe for the same purpose; the belt prevented girls and women from engaging in unlawful or unsanctioned sex. This method caused little permanent physical damage to the individual. Genital surgery was permitted in North America and Europe in the late nineteenth century with the intention of curing nymphomania, masturbation, hysteria, depression, epilepsy, and insanity. There is no evidence that such surgery was associated with any ritualistic activity. Elsewhere, the surgery has historical links with either religious or ethnic rituals. It is believed that the ancient Egyptians and ancient Arabs practiced this form of surgery. Genital mutilation seems to have been transplanted to Latin America from Africa during the slave trade and may have taken root first in the central part of Brazil, where groups of West Africans were resettled after the abolition of the slave trade in the middle of the nineteenth century, and to eastern Mexico and Peru through migration. In Asia genital mutilation is found among Islamic religious groups in the Philippines, Malaysia, Pakistan, and Indonesia. Where the mutilation exists in the Middle East and Asia, it is strongly associated with Islam. Female genital mutilation is not practiced in all Islamic countries. Those societies known to practice it, namely, the United Arab Emirates, South Yemen, Oman, and Bahrain in the Middle East, and northern Egypt, Mauritania, Sudan, Somalia, Mali, and Nigeria in Africa, probably inherited it from pre-Islamic cultures.

Alleged Benefits of Female Circumcision

The modern defense of female circumcision allows us to reconstruct the ancient rules that governed moral action or behavior in polygamous communities. The defense enumerates a wide range of health-related and social benefits alleged to result from the practice:

1. maintenance of cleanliness;
2. maintenance of good health;
3. preservation of virginity;
4. enhancement of fertility;
5. prevention of stillbirths in women pregnant for the first time;
6. prevention of promiscuity;
7. increase of matrimonial opportunities;
8. pursuance of aesthetics;
9. improvement of male sexual performance and pleasure; and
10. promotion of social and political cohesion.

Cleanliness is regarded as a great virtue by women in countries where the practice is common. In some cultures, particularly in Africa, women are required to cleanse their genitalia with soap and water after urinating. Those who justify removing parts of the genitalia that produce secretions cite this preoccupation with the cleanliness of the genital organs. Some traditional circumcision societies claim that circumcised women are generally healthy and that the operation cures women suffering from problems resembling those identified in nontraditional societies as depression, melancholia, nymphomania, hysteria, insanity, epilepsy, and the social disorder of kleptomania. In situations where proof of virginity is essential for concluding a marriage transaction, circumcision is believed to be the guarantee against premarital sex. This guarantee benefits parents who are able to demand a high bridal price for their daughters. Marriage immediately after the transaction ceremony is common, and such marriages, involving pubertal girls, are usually followed by pregnancy within a very short time. Circumcised girls and women are regarded as having an advantage over the uncircumcised in marrying. Where female genital mutilation is an established custom, tradition

FIGURE 1

forbids men to marry uncircumcised girls; hence, circumcision of girls ensures they will be marriageable. Certain traditional communities, such as the Mossi of Burkina Faso and the Ibos of Nigeria, believe that a firstborn child or even subsequent babies will die if their heads touch a mother's clitoris during the birth process. The clitoris is therefore removed at the time of delivery if this has not already been done. Since female genital mutilation reduces or even eliminates sexual pleasure, the practice presumably eliminates the risk of female promiscuity. The justification of the practice to preserve chastity, eliminate promiscuity, foster or improve sexual relations with men, generate greater matrimonial opportunities, protect virginity, and increase fertility reflects the existence in traditional societies of strict controls on social behavior.

The belief that circumcision enhances beauty stems from the claim that the male prepuce or foreskin is removed mainly for aesthetic reasons, and that the clitoris, the female counterpart to the penis, should be removed for the same reason. If left intact, the clitoris is believed likely to grow to an embarrassing and uncomfortable size. In some patriarchal societies, female genital mutilation is also said to benefit the male by prolonging his sexual pleasure, since the clitoris is thought to increase male excitement during sexual inter-course with a female partner and may rush a man's orgasm. Of great importance to women in such cultures is the status circumcision bestows on the circumcised. It entitles them to positions of religious, political, and social leadership and responsibility.

The argument in favor of circumcision serves narrow social interests and does not achieve the goods desired or guaranteed. Failure to achieve these goods, moreover, is often blamed on the woman rather than the ritual. For example, maintaining cleanliness becomes an agonizing task. The hardened scar and stump that result from circumcision are unsightly, and they halt the flow of urine and menstrual blood through the normal channels. This obstruction causes unnecessary fluid retention and results in odors more disagreeable than those from the natural hormonal secretions that tradition teaches are degrading. Associating the death of babies at childbirth with clitoral contact is clearly refuted by the evidence that millions of healthy babies are born to uncircumcised mothers.

While the desire of organized society to maintain control over people's actions may be understandable, not all such control promotes their well-being or self-determination. Such rituals also cause harm to society by increasing morbidity and mortality levels. In addition, although these rites may promote social and political cohesion, they thwart the individual's freedom to determine what is right and in her best interests. Even women who learn that circumcision is an unsafe and harmful practice may feel pressure from society to agree to it for themselves or their children in order to marry or remain members of the group.

Harmful Effects of Female Circumcision or Female Genital Mutilation

The medical consequences of female genital mutilation are quite grave (El Dareer; Koso-Thomas). In Africa an estimated ninety million females are affected (Hosken). Three levels of health problems are associated with the practice. Immediate problems include pain, shock, hemorrhage, acute urinary retention, urinary infection, septicemia, blood poisoning, fever, tetanus, and death. Occasionally, force is applied to position candidates for the operation, and as a result, fractures of the clavicle, humerus, or femur have occurred. Intermediate complications include pelvic infection, painful menstrual periods, painful and difficult sexual intercourse, formation of cysts and abscesses, excessive growth of scar tissue, and the development of prolapse and fistulae. A fistula is an abnormal passage: a hole (opening) between the posterior urinary bladder wall and the vagina or a hole between the anterior rectal wall and the vagina. Late complications include accumulation of menstrual blood of many months or even years, primary infertility, painful clitoral tumors, recurrent urinary tract infections, and kidney or bladder stone formation. Obstetric complications such as third-degree perineal tear, resulting in anal incontinence and fissure formation, and prolonged and obstructed labor are also known to occur. Psychological problems of anxiety, frigidity, and depression, as a result of the physical inability to have a clitoral orgasm, may also develop.

Women who undergo circumcision suffer various degrees of emotional and mental distress depending on the nature of complications following their operation. Records show that 83 percent of all females undergoing circumcision are likely to be affected by some condition related to that surgical procedure requiring medical attention at some time during their lives. This level of health risk should be of concern to nations with a large proportion of circumcised women, because such women may never make the progress toward the economic and social development required of them.

Application of Modern Medical Practice to Female Genital Mutilation

Modern medicine has made impressive strides in investigating, preventing, and treating a wide range of ailments. Through its investigative approaches it has judged that unwarranted surgery is wrong. In the case of female genital mutilation, studies have found that certain of the resulting medical conditions are serious and can lead to complications and permanent health damage requiring both medical treatment and counseling (Koso-Thomas). Awareness of female genital mutilation's harmful effects has encouraged changes in how the operation is performed, changes that may include sterilization of equipment and dressings and administration of local anesthetic, antibiotics, and antitetanus injections prior to circumcision.

Ethical Aspects

Since some followers of Islam in Africa, the Far East, and the Middle East endorse circumcision, it has been widely identified as an Islamic rite. However, female genital mutilation is not practiced in Saudi Arabia, Algeria, Iran, Iraq, Libya, Morocco, or Tunisia. Many Islamic and Christian religious leaders have categorically denied that female circumcision or female genital mutilation is an injunction in the Qur'an or a "commandment" in the Bible. Since the foundations of the practice lie outside Islamic or Christian religious law, the origins of circumcision and its justification must lie in the moral, social, and religious structure and operation of societies practicing it. Individuals practicing it act within a system of rules that strictly regulate sexual behavior in society. Female genital mutilation generally thrives in communities with strictly enforced conventions and social rules. With the knowledge of its harmful effects now common, no social system endorsing this kind of mutilation can be said to promote a favorable climate for a fulfilling life.

The attitudes of women toward circumcision depend on their experiences and level of education. Most women affected by the practice are unaware that circumcision is the cause of their health difficulties (Koso-Thomas). Once aware of this relationship, however, many women who have some education and training and who are exposed to a modern environment are better able to assess what is involved in circumcision actions and, on that basis, to make a reasoned judgment of its rightness or wrongness. Many such women have come to believe that the practice is unacceptable and have refused to allow their female children to go through the same traumatic experience. Many feminists and health professionals have openly displayed a higher regard for women's health than for tradition.

It has been shown, however, that some women who admit to suffering under the unexpected effects of the operation still feel obliged to support the practice. A study carried out to obtain opinions on circumcision involving 135 men and 120 women showed that 25 percent were shocked at what happened to them on their circumcision day, as it was not what they had expected (Koso-Thomas). The majority of them, either semi- or nonliterate, believed that they had done the right thing and planned to have their daughters circumcised. Those women who were not shocked by their experiences were also mainly illiterate and did not see why their daughters should not undergo circumcision. The attitude of men in the sample also varied according to their level of education. Illiterate men insisted that all women should be circumcised to keep them in their place, while the literate men argued that women should be given a choice as to whether or not to be circumcised. They felt that to deny women this choice was a violation of their human rights. It has also been found that circumcision is supported in most women's organizations, particularly political and social groups, since these groups reflect the feelings of the majority in the community.

Usually the decision to have a girl circumcised is made by the female elder members of the family/clan who insist on carrying out the procedure. An aura of secrecy, celebration, and pride surrounds the circumcision and encourages voluntarism on the part of recruits by making membership in the group seem more attractive. A few educated women, however, who have had access to modern medical assessment of their health as well as information on the dangers of the practice also support circumcision but advocate changes to reduce its health hazards. A few healthcare personnel have felt that medical intervention at the early stages of the operation might prevent the more serious health consequences of circumcision. Since circumcision cannot take place without health consequences, the position of these women and health practitioners is untenable.

Women who live in a traditional environment tend to judge their actions on the basis of traditional rules and principles of their society. There may be some misogynistic attitudes among such women, but the dominant force directing their actions comes from the society that demands, among other things, that this ritual be performed in order for them to qualify for marriage and social acceptance.

There are also attitudes inherent in African sexuality that not only permit circumcision but foster it. In most African cultures, sexuality is regarded as a gift to be used for the procreation of the human species, and any public or even private display of sex-related feeling or enjoyment is seen as debasing this gift. In some communities, only a token expression of the sexual self is permitted. The issue of sexual fulfillment is unimportant. Thus, controls over the sexual behavior of women are designed to curb female sexual desire and response and to encourage disregard for the sexual aspects of their lives. The removal of the organ or organs responsible for sexual stimulation is therefore taken as necessary for the fixation of certain values within the community and for ensuring the acceptance of rigid standards of sexual conduct. Thus, the underlying concern of those who defend the institution of female circumcision is that women's sexuality will be corrupted if women are allowed the freedom to control it or indeed to pursue the personal satisfaction of their sexual desire. Implicit in this argument is the major premise that it is immoral for a woman to act on her sexual desire. Women who still support the practice continue to promote injury with confirmed medical consequences. In this respect the role of the healthcare practitioner in the society is crucial and may lead to personal dilemmas that have to be resolved. Many feel anger against the executors and supporters of the ritual and sadness at the futility of the exercise and at the intransigence of traditional circumcising communities. Healthcare professionals presented with the choice of treating or not treating women who have chosen to be circumcised are often determined to rescue a life they see as poised on the brink of destruction. On the other hand, traditional circumcisers have no moral dilemmas about the practice. They believe that they have no choice in a matter which concerns the preservation of their cultural heritage. That heritage dictates how women must live, and to them, life should be one of happiness in subservience to the will of the people and in obedience to customary and religious laws.

olayinka a. koso-thomas (1995)

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