Female genital mutilation (FGM), in which the girls’ female genital organs are injured, is a common practice across Africa. This often painful and dangerous experience can damage a girl or woman for the rest of her life. Sometimes girls do not survive the procedure because they bleed to death or die of an infection.

FGM is internationally considered as a violation of the human rights of girls and women; it has no health benefits and involves removing and damaging healthy and normal female genital tissue and interferes with the natural functions of women’s bodies. Since this ritual is often deeply imbedded in a culture, it is also difficult to stop it. Several ngo's try to do something about it. One of these ngo's is AMREF. In close cooperation with the local population it established a suitable alternative for this ritual amongst the Maasai in Kenya.

According to the WHO, FGM is practiced in 28 African countries, in parts of the Middle East and by some immigrant communities in Europe, North America and Australasia. The WHO estimates that around 92 million women and girls in Africa, and 140 million women worldwide have experienced the procedure. Several African countries have enacted legislation against it, including Burkina Faso, Central African Republic, Djibouti, Eritrea, Ethiopia, Togo, and Uganda.

What is FGM?

Female genital mutilation is the term used to refer to the removal of part, or all, of the female genitalia. This is also known as female genital cutting (FGC) and female circumcision. The term female genital cutting is often used by many organizations, because this term is better received in the communities that practice it.

The WHO classified FGM into four types: removal of the clitoral hood, almost always accompanied by removal of the clitoris itself; removal of the clitoris and the inner labia; removal of all or part of the inner and outer labia and usually the clitoris. It includes the fusion of the wound, leaving a small hole for the passage of urine and menstrual blood. This wound is opened for intercourse and giving childbirth; this category contains all other harmful procedures to the female genitalia for non-medical purposes. Such as a symbolic piercing or pricking of the clitoris or labia, cutting in the vagina or introducing corrosive substances to widen it.

When and how?

FGM is usually carried on girls from a few days old to puberty or even the first pregnancy. But most commonly it occurs between the ages between 4 and 8. It may take place in a hospital, but is usually performed by a traditional circumciser using a knife, razor or scissors and without anaesthesia. The person performing the mutilation may be an older woman, a traditional midwife, a healer, barber, or a qualified midwife or doctor. The girl is immobilized, held, usually by older women, with her legs open. Antiseptic powder may be applied, or, more usually pastes (containing herbs, milk, eggs, ashes or dung) which are believed to facilitate healing. The girl may be taken to a specially designated place to recover where, if the mutilation has been carried out as part of an initiation ceremony, traditional teaching is imparted

Infibulation

The most severe form of FGM is infibulation, also known as Pharaonic circumcision. This term stems from its practice in Ancient Egypt under the Pharaohs, and "fibula" (in infibulation) refers to the Roman practice of piercing the outer labia with a fibula, or brooch. Even among Egyptian mummies genitally-mutilated females have been found.

After infibulation the girl's legs are tied together from hip to ankle for up to forty days to allow the wound to heal; this immobility causes the labial tissue to bond, forming a wall of flesh and skin across the entire vulva, apart from a hole the size of a matchstick for the passage of urine and menstrual blood, which is created by inserting a twig or rock salt into the wound. Bleeding is profuse, but is usually controlled by the application of various bandages, the threading of the edges of the skin with thorns, or clasping them between the edges of a split cane.

When an infibulated girl is married sexual problems can occur; the penetration of the bride's infibulation takes anywhere from 3 or 4 days to several months. Some men are unable to penetrate their wives at all and the task is often accomplished by a midwife under conditions of great secrecy, since this reflects negatively on the man's potency. A great deal of marital anal intercourse takes place in cases where the wife cannot be penetrated. Those men who do manage to penetrate their wives do so often, or perhaps always, with the help of a little knife. Some new wives are seriously damaged by unskilful cutting carried out by their husbands. A possible additional problem resulting from all types of female genital mutilation is that lasting damage to the genital area can increase the risk of HIV transmission during intercourse.

Reasons for FGM

There are various reasons why FGM is carried out. Often it is a custom and tradition, mostly as an initiation of adulthood; a girl cannot be considered an adult in a FGM-practicing society unless she has undergone FGM. There usually is also social pressure to conform to what others do and have been doing.

Gender identity is a second reason: a girl will not be considered a complete woman (and therefore be married) in some cultures. FGM is considered by its practitioners to be an essential part of raising a girl properly; girls are regarded as having been cleansed by the removal of the “male” body parts. In many societies it is believed that FGM reduces a woman’s desire for sex and therefore reducing the chance of sex outside the marriage. In case of infibulation a woman is “sewn up” and “opened only for her husband. The honour of the family is seen to be dependent on this.

Furthermore cleanliness and hygiene are justifications for FGM. The popular terms for FGM are often synonymous for purification. In some societies unmutilated women are regarded as unclean and cannot handle food and water. Some groups see the clitoris as dangerous, capable of killing a man if his penis touches it or a baby if the head comes into contact with it during birth. Also often a woman’s unmutilated genitals are seen as ugly and bulky. In some cultures it is believed that clitoridectomy makes childbirth safer.

Often religion is given as a reason, although FGM is not practiced by the majority of Muslims or predated in the Islam.

Health complications

The effects of genital mutilation can lead to death. At the time the mutilation is carried out, pain, shock, haemorrhage and damage to the organs surrounding the clitoris and labia can occur. Immediate complications are increased when FGM is performed in traditional ways, and without access to medical resources: the procedure is extremely painful and a bleeding complication can be fatal. Other immediate complications include acute urinary retention, urinary infection, wound infection, blood poisoning, tetanus, and in case of unsterile and reused instruments, hepatitis and HIV. Late complications may vary depending on the type of FGM performed. The formation of scars and keloids can lead to strictures, obstruction or fistula formation of the urinary and genital tracts. It can also lead to damage to urethra and bladder with infections and incontinence. Furthermore it can lead to vaginal and pelvic infections, heavy menstrual pain, painful sexual intercourse, stones in the bladder and urethra, kidney damage and infertility. Complete obstruction of the vagina results in hematocolpos and hematometra. Other complications include epidermoid cysts that may become infected, neuroma formation, typically involving nerves that supplied the clitoris, and pelvic pain.

FGM and pregnancy

FGM may complicate pregnancy and place women at higher risk for obstetrical problems, which are more common with the more extensive FGM procedures such as infibulation. Prenatal care and diagnosis of certain conditions, such as preeclampsia is difficult for infibulated women who have developed vesicovaginal or rectovaginal fistulae. Neonatal mortality is increased in women with FGM. The WHO estimated that additional 10–20 babies die per 1000 deliveries as a result of FGM. During childbirth, existing scar tissue on excised women may tear. Infibulated women, whose genitals have been tightly closed, have to be cut to allow the baby to emerge. If no attendant is present to do this, perineal tears or obstructed labour can occur. After giving birth, women are often reinfibulated to make them tight for their husbands. The constant cutting and restitching of a woman’s genitals with each birth can result in tough scar tissue in the genital area.

Alternative ceremonies

Sometimes the mutilation is part of an initiation rite and the festivities are major events for the community. This is the case with the Maasai. The Maasai are a patriarchal society, meaning that men take all the decisions and women have little to say. The life of Maasai girls is marked by early marriage, limited schooling, illiteracy, frequent child bearing, social isolation and limited options in life. Usually Maasai girls will be circumcised around the age of 13, as part of their initiation rite to become a woman. Their vaginal labia and often also their clitoris are removed during this ritual. Normally several girls take place in the ritual and will be circumcised at the same time. FGM is basically done because Maasai men do not want to marry an uncircumcised girl. Circumcised girls are seen as clean women and ready to be married. Many of them have to leave school and marry soon afterwards.

The ngo AMREF knows the health risks of FGM and therefore wants to help communities to abolish this practice. In close cooperation with the local people the organization is looking for solutions. Informing people about the dangers and health risks of FGM is very important here. Since the men and mostly the elders of the village take the decisions for the village, they are closely involved in the search for alternatives. Also young men (the “morans”, or warriors of the group) need to be convinced that it is acceptable to marry an uncircumcised woman. AMREF, together with the population, came up with an alternative ritual for FGM for the Maasai in Magadi and Loitokitok, situated in Kajiado County, Kenya. This new ritual, already undergone by 546 girls, does not involve cutting or health risks. It takes 4 days, the same time as the traditional FGM ceremony. Many customs are still the same: specially for this ritual designed clothes and jewellery, blessings with tufts of grass sprinkled with milk and water by the village elders, dancing and singing of traditional songs. The last day, which the girl spends in a hut in the company of her mother and other women who teach her the "lessons of life" is also kept the same. The big difference is that the girl will not be circumcised anymore in this hut.

The wise elder men of the village, who make all the decisions for the girls, decided how the alternative ritual should look like. They choose for education instead of circumcision; now the girls receive lessons about human rights, sexual education and self consciousness - which was also their wish. At day 4, the last day, the fathers create arches made of branches with the help of the elders. The girls go singing and dancing underneath these arches to reach their new status as a woman. Thanks to this safe initiation ritual these girls have more change and rights of a better health. Still 96% of the Maasai girls are circumcised, but the ceremony in Magadi and Loitokitok is a good start and an example to change the old FGM tradition into a new one without health risks.

* Jacqueline Lampe is director of AMREF in the Netherlands.