Female Genital Mutilation Primer (by Junomedical)
The following article has been published on Junomedical, and we would like to share it with our readers to give more detailed information on the issue of Female Genital Mutilation.
The following material is designed to be a primer for individuals seeking information about Female Genital Mutilation (FGM). It will provide an overview of the practice and its place in modern society, medical ramifications and available corrective procedures, as well as a list of resources for treatment and further reading. We have tried to be as objective as possible in presenting the most accurate information available, but it is the responsibility of each individual to conduct their own research beyond this guide. If there is information that we have missed out or are as of yet unaware of, please let us know by emailing firstname.lastname@example.org.
Terminology related to Female Genital Mutilation
There is much debate surrounding the appropriate terminology to use when discussing this topic. While the term Female Genital Mutilation (FGM) accurately describes the physical experience endured, for many girls and women, the memory of their experience is painful and traumatic, so other terms used include Female Genital Cutting (FGC), traditional cutting, or female circumcision (FC), even though it bears no resemblance to male circumcision.
To understand FGM, it is important to specify the female anatomy being referenced:
Vulva: External female genitalia, comprising the opening of the vagina, labia minora, labia majora, and clitoris
Labia minora: Inner lips of the vagina
Labia majora: Outer lips of the vagina
Clitoris: A female sex organ; the visible, button-like portion (glans) is near the front junction of the labia minora, above the opening of the urethra. Beneath the surface, the clitoris extends around the vagina, and comprises a vast network of nerves and nerve endings, an estimated 8000 of which are concentrated on the glans. This is what makes the clitoris the female's most sensitive erogenous zone and the primary anatomical source of female sexual pleasure.
Prepuce: The fold of skin surrounding the clitoris
What is Female Genital Mutilation?
FGM is a socio-cultural practice that involves the removal of a girl or woman’s external genitals. In 1997 the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and the United Nations Population Fund (UNFPA) issued a joint statement defining FGM as "all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or other non- therapeutic reasons."
(WHO Female Genital Mutilation – Fact sheet N°241, updated February 2014)
FGM has no health benefits and is painful, traumatic, and harmful to girls and women. The practice constitutes an extreme form of child abuse, as well as violence and discrimination against women and girls.
What are the Human Rights implications of Female Genital Mutilation?
FGM reflects a deep-rooted inequality between the sexes, and is internationally recognized as a human rights violation. The practice is condemned by a number of international treaties and conventions, as well as by national legislation in many countries.
The Office of the United Nations High Commissioner for Human Rights (OHCHR) - a United Nations agency that works to promote and protect human rights - states that “everyone has the right to a standard of living adequate for health and well-being.” This statement has been used to argue that FGM violates the right to health and bodily integrity. In 2003, the International Day of Zero Tolerance for Female Genital Mutilation was established by the UN to raise awareness of, and coordinate efforts to eliminate FGM.
In order to tackle FGM and create a world where women and girls live in dignity, are healthy, have choices, and equal opportunities, it is crucial that public education and training, advice and support, and community engagement are made available.
Why is Female Genital Mutilation performed?
The practice of FGM predates organized religion and has no religious significance in Islam, Christianity, Judaism, or any other major world religion. Despite this, FGM is practiced by people of all faiths in Africa, even though no religion or indigenous faith requires it. It is believed that the tradition of FGM may have originated in ancient Egypt at the time of the Pharaohs. Due to a lack of education, FGM is prevalent in rural communities and performed for one or more of the following socio-cultural reasons:
- FGM is seen as a rite of passage for women.
- Many believe that FGM makes the vaginal area more hygienic.
- Social pressure: in communities where most women have undergone FGM, relatives and friends create an environment in which the practice becomes required for social acceptance.
- Control over a woman’s sexuality: many believe that reducing sexual fulfillment will cleanse or purify the female.
- FGM is seen as a means to ensure a woman remains sexually chaste and to prevent her from being unfaithful to her spouse.
- Custom and tradition: communities that practice FGM maintain their customs and preserve their cultural identity by continuing the tradition.
When is Female Genital Mutilation performed?
The age at which FGM is performed has always varied, but in recent years, there has been a drastic decrease in average age, with reports of FGM occurring as early as a few days after birth. Girls between the ages of 4 and 12 regularly undergo the procedure as a rite of passage, while others undergo FGM immediately prior to marriage or after their first pregnancy.
(UNICEF, 2013, Female Genital Mutilation/Cutting: A statistical overview and exploration of the dynamics of change)
Where is Female Genital Mutilation practiced?
FGM is known to be practised in at least 29 African countries, as well as in some communities in the Middle East and Asia, and increasingly among migrant communities in Europe, the United States, Canada, New Zealand, and Australia.
How is Female Genital Mutilation performed?
There are several different types of FGM, categorized based on the extent of the cuts made to the female anatomy. According to the WHO, the different types of FGM can be described as follows:
- Type 1: Partial or total removal of the visible part of the clitoris and/or the prepuce.
- Type 1a: Removal of the clitoral hood or prepuce only.
Type 1b: Removal of the clitoris with the prepuce.
Type 2: Partial or total removal of the clitoris and the labia minora, with or without removal of the labia majora.
Type 2a: Removal of the labia minora only.
Type 2b: Partial or total removal of the clitoris and the labia minora.
Type 2c: Partial or total removal of the clitoris, the labia minora, and the labia majora.
Type 3: Also known as Infibulation, this kind of FGM involves stitching together the vaginal orifice by cutting and repositioning the labia minora and/or the labia majora, with or without excision of the clitoris. A 2mm to 3mm hole is left for the passage of urine and menstrual fluid. To allow for sexual intercourse, the vagina is either sliced open with a knife or penetrated by a male's penis after having healed shut; this is known as defibulation or de-infibulation.
Type 3a: Removal and repositioning of the labia minora.
Type 3b: Removal and repositioning of the labia majora.
Type 4: All other harmful procedures to female genitalia for non-medical purposes. These can include pricking, piercing, and incisions of the clitoris and/or labia, cauterization by burning the clitoris and surrounding tissues, incisions to the vaginal wall, scraping or cutting of the vagina and surrounding tissues, stretching of the labia, and the insertion of corrosive substances or herbs into the vagina.
What are the consequences of Female Genital Mutilation?
FGM inflicts major physical and psychological damage on the girl or woman on whom it is performed. Removing or damaging healthy, normal genital tissue prevents the natural functioning of the body and can cause a number of immediate and long-term health consequences.
- Chronic pain
- Excessive bleeding
- Urination problems
- Swelling of genital tissue
- Psychological trauma
- Gangrene: a type of necrosis (the premature death of cells in living tissue) caused by a critically insufficient blood supply
- Tetanus or lockjaw: an infection characterized by muscle spasms
- Endometritis: inflammation of the inner lining of the uterus
- Severe infections which can lead to shock, and in some cases, death
- Painful periods
- Pain during sexual intercourse
- Pain and difficulty urinating
- Psychological issues including, depression, anxiety, panic attacks, and post-traumatic stress disorder
- Development of cysts
- Difficulty in undergoing cervical screening
- Reproductive tract infection
- Complications during pregnancy and childbirth
- Increased risk of perinatal deaths
The number of girls and women who die as a result of the practice is unknown because complications may not be recognized or reported.
Can Female Genital Mutilation be reversed?
There are procedures which can, to some extent, repair or reverse the physical damage caused by FGM.
When the vaginal orifice is stitched together by cutting and repositioning the labia minora and/or the labia majora in a practice called infibulation (Type 3 FGM), it can be reopened surgically using a technique called defibulation or de-infibulation. The aim is to restore the vaginal opening to its previous form and function before the FGM procedure was carried out.
How is defibulation performed?
Defibulation can be performed under local anesthetic and patients won't usually need to stay in hospital overnight. During the surgery the labia is re-opened and scar tissue is removed. The skin at either side of the scar will be stitched to keep it from healing together again and patients usually heal very quickly. The stitches used will dissolve so patients will not need to have them removed.
What kind of results can be expected from defibulation?
Defibulation surgery is sometimes referred to as a "reversal" although this name is misleading, as the procedure doesn’t replace any removed tissue, and will not undo the damage caused, including emotional damage. Although the procedure can restore female attributes to the vagina, it is important to understand that structures such as the labia, hymen or clitoris that may have been compromised from the original procedure may not be able to be restored in their entirety. Having said this, the surgery can alleviate many of the complications that result from FGM:
Following surgery, women are able to engage in sexual relations with less pain, prejudice, or self-awareness Natural childbirth is possible Women and girls are able to pass urine and menstrual fluid normally The surgery can eliminate or reduce the post-traumatic stress resulting from FGM
Clitoroplasty is the surgical restoration of a clitoris. The procedure offers hope to women who have had the visible part of their clitorises removed, and who suffer painful side effects and a loss of sexual pleasure as a result.
The clitoris is a large, complex organ that extends throughout the female reproductive anatomy, so when a woman is subjected to type 1, 2, or 3 FGM, only the visible part of the clitoris is actually removed. Beneath the surface, the clitoris has a root that is about 10cm long and arches around the vagina. It is this larger network of nerves that reconstructive surgeons use to rebuild a working organ.
How is a clitoroplasty performed?
Clitoroplasty surgery is performed under general anesthesia. During the procedure, scar tissue is removed from the vulva and the nerves buried underneath are exposed. The clitoris is then lowered by cutting ligaments that support it, while still preserving nerves and blood vessels. Subsequently, fresh tissue is grafted on to reconstruct a clitoral glans.
What kind of results can be expected from clitoroplasty surgery?
Months of healing are required for the patient to gain sensation in the newly exposed tissue. However, once healed, patients experience several benefits, including:
- Improved cosmetic appearance
- Reduction in chronic pain
- Reduction in risk of infection
- Increase in clitoral sensitivity and sensation
In addition to these tangible improvements, patients report feeling that their identity and femininity has been restored, with many women experiencing orgasms for the first time.
What are the risks of Female Genital Mutilation reconstruction procedures?
As with any medical procedure, there are potential side effects and risks, including bleeding, infection, and soreness, which can last roughly one week. Although the majority of women who undergo clitoroplasty experience less pain and more sensation after the surgery, up to 5% of patients feel less sensation afterwards.
To minimize any postoperative complications, patients are advised to select a surgeon experienced in FGM reconstruction surgery, and to follow all recommended care. Most surgeons will highly encourage patients to seek psychiatric support in the weeks and months prior to and following the procedure, to ensure that psychological healing happens simultaneously with physical reconstruction.
Who performs Female Genital Mutilation reconstruction surgery?
Please see the links below for our shortlist of surgeons specializing in reconstructive FGM surgery around the world, and organizations which provide treatment and information.
[Dr. Pierre Foldès (France)](http://clinique-st-germain.fr/docteur-Pierre-FOLDES-Urologie-saint-germain-en-laye-78.html)
Although reconstructive surgery to repair the physical damage of FGM has been around for decades, the technique to restore clitoral function was only developed in 2004 by French urologist and surgeon Pierre Foldès. His goal was to rebuild nerve networks while reconstructing the clitoris, in order to restore sexual sensation. Dr. Foldès currently operates on approximately 200 women per year.
[Dr. Marci Bowers (U.S.A. & Burkina Faso)](http://marcibowers.com/our-services/fgm/)
Dr. Bowers learned the clitoroplasty technique from Dr. Pierre Foldès. She became involved in FGM reconstruction surgeries because of Clitoraid, a private, non-profit organization that helped fund her training in Paris. She performs surgeries in California and at The Pleasure Hospital in Burkina Faso for free, but patients still have to cover the costs of the operating theater and anesthesia.
[Dr. Friedman (U.S.A.)](https://www.friedmanplastics.com/plastic-surgery/defibulations-for-fgm/)
CLITORAID is a private, non-profit organization which treats women and girls who have undergone FGM.
[Desert Flower Centers](http://www.desertflowerfoundation.org/en/desert-flower-center.html) provide reconstructive FGM surgery in Berlin, Paris, and Stockholm.
Who is at risk of being subjected to Female Genital Mutilation?
Girls living in communities that practise FGM are most at risk of being to subjected to the procedure. Girls are also at risk of being made to undergo FGM if their mother, sister, or a member of their extended family has had the procedure. Immigration from African and Middle Eastern countries where FGM is deeply ingrained in the culture is the sole factor for the rise in FGM numbers in Europe, North America, Australia, and New Zealand. The following figures give an overview of how many women and girls are affected by FGM around the world.
Worldwide: In 2016 UNICEF estimated that 200 million women and girls alive today have been subjected to FGM. 3 million undergo the procedure every year.
Africa: The World Health Organization estimates that nearly 30 million girls in Africa are at risk of being subjected to FGM over the next decade.
Europe: In 2013 the European Parliament estimated that 180,000 women and girls were at risk of being subjected to FGM in the European Union (30,000 of whom were living in the UK).*
U.S.A.: More than 500,000 women and girls in the U.S. had undergone or were at risk of undergoing FGM in the U.S. according to the Population Reference Bureau (PRB).
*European Parliament Resolution of 24 March 2009 on combating female genital mutilation; EIGE Report on FGM in the European Union and Croatia, 2013
What can be done if you or someone you know is at risk of Female Genital Mutilation?
In many cases of FGM occurring outside of Africa and the Middle East, parents may attempt to remove their child from local jurisdiction where FGM is illegal. In this way, FGM can be performed in another part of the world where it is more readily available and not criminalized.
If you or someone you know is in immediate danger, contact the police immediately. If you or someone you know is at risk of undergoing FGM, contact local authorities or seek information from one of the sources provided below. If you are under pressure to have FGM performed on your daughter or other relative, ask your GP, health visitor, or other healthcare professional for help.
The following list of organizations provide help to those who have been subjected to or are at risk of being subjected to FGM. Click on the links to find out more:
- UNICEF works in 190 countries and territories to protect the rights of children.
- United Nations Population Fund (UNFPA) address reproductive health and population issues, and raises awareness of these issues in all countries.
- UNFPA, jointly with UNICEF, leads the largest [global program to accelerate the abandonment of FGM] (http://www.unfpa.org/female-genital-mutilation#sthash.jsL0PT7F.dpuf)
- FORWARD (Foundation for Women’s Health, Research and Development) is a women-led campaign and support charity dedicated to advancing and safeguarding the health and rights of African girls and women. It operates in the UK and Africa.
- Plan International is a children’s rights organization working with communities in several countries.
- Desert Flower Foundation aims to raise awareness of and ultimately eradicate FGM.
END FGM European Campaign (EU-wide)
TERRE DES FEMMES (Germany)
Daughters of Eve (UK)
Alliance Globale Contre FGM (Switzerland)