FGM Strategies for eradication

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                 FEMALE GENITAL MUTILATION:
                 STRATEGIES FOR ERADICATION
                                        Fran P. Hosken

   Presented at The First International Symposium on Circumcision, Anaheim, California,
                                      March 1-2, 1989.



     Female genital mutilation - the descriptive term for the different types of operations are
"excision" and "infibulation" - continues to be practiced in large regions of Africa, from the
Red Sea Coast to the shores of the Atlantic. According to a conservative estimate, at least 84
[110] million women and girls are mutilated today in Continental Africa and similar
operations are practiced along the Persian Gulf and the southern part of the Arab Peninsula.
In Indonesia and Malaysia, less drastic forms of "female circumcision" are practiced by some
of the Moslem populations of this region and sporadic occurrences have been registered
among other mainly Moslem groups.




    With increasing mobility of African and Middle Eastern immigrants to Europe, the U.S.
and also to Australia, these mutilations are being exported all over the world. Indeed, Britain
had to pass special legislation recently to prohibit the operations (which were carried out by
obliging physicians for a high fee). In France, the Criminal Courts had to finally initiate
proceedings against African fathers and families after three little girls died as a result of the
operations performed in France. One father brought to court had "operated" on his baby
daughter with a pocket knife - the child bled to death.

     In most European countries and also in Australia, health services have been alerted to
warn people and especially immigrants. In the U.S., immigrants from affected African
countries have not been warned by immigration services that these mutilations are
categorized as gross child abuse and would result in having children removed from parents by
the Social Services. There is no doubt, and anecdotal evidence exists, that immigrants from
Somalia, Sudan, Ethiopia, or certain ethnic groups of Kenya, Nigeria, etc., are having their
small daughters mutilated in the U.S.

    A systematic survey has yet to be done to document the facts on how many children are
involved or are at risk - and this is long overdue (see below).

    But first, the medical and health facts need to be established.

     The medical literature describes "circumcision" or "sunna circumcision" as the removal
of the clitoral prepuce and the tip of the clitoris. "Sunna" means tradition in Arabic. But to
remove the prepuce of the clitoris, which is a very delicate operation especially if done on a
child, would require great skill, good light, surgical tools, an anesthetized, motionless body,
quite aside from a thorough knowledge of anatomy.

     None of these conditions exist where these operations are done in Africa and the Middle
East on struggling, screaming children held down by force on the ground in dark huts, with
crude knives or any other cutting tools. What is done in reality is cutting away whatever the
operator can get hold of, part or all of the clitoris and often part of the labia minora (small
lips).

     Excision or clitoridectomy, the operation most frequently done throughout Africa,
consists of the removal of the entire clitoris, usually together with the adjacent parts of the
labia minor (small lips) and sometimes all of the external genitalia, except parts of the labia
majora (large lips). Some operators make additional cuts to enlarge the opening of the vagina
as this is believed to make childbirth easier. (The opposite is true.)
     Infibulation or pharaonic circumcision (excision with infibulation) means that the entire
clitoris and the labia minora are cut away and the two sides of the labia majora are partially
sliced off or scraped raw and then sewn together, often with catgut. In Sudan and Somalia,
thorns are used to hold the two bleeding sides of the vulva together, or a paste of gum arabic,
sugar and egg is used. The introitus or entrance to the vagina is thus obliterated which is the
purpose of the operation, except for a tiny opening in the back to allow urine, and later
menstrual blood, to drain. The legs of the girl are tied together immediately after the
operation, and she is immobilized for several weeks until the wound of the vulva has closed,
except for a small opening that is created by inserting a splinter of wood or bamboo.

    The mortality of girls and women due to all these operations no doubt is high; but no
records are kept anywhere. Primary fatalities are not recorded and death in childbirth due to
obstructed labor is never related to genital operations anywhere. But the terrible
psychological trauma that is lifelong has never been investigated from a woman's view.

     The objective of infibulation is to make sexual intercourse impossible. At present,
infibulation is practiced mostly by Moslems, according to all available sources, because of
the importance and value they attach to virginity. Infibulation is performed to guarantee that a
bride is intact - the smaller her opening, the higher the bride price. A girl is often inspected by
the female relatives of the husband-to-be before the bride price is paid. The bride price,
whereby the husband or his father pays the father of the girl a considerable sum in cash or
kind, is still a marriage requirement almost everywhere in Africa and the Middle East.

     Infibulation may also occur spontaneously by adherence of the wounded sides of the
labia, especially where extensive excision operations are performed. For instance, in parts of
Mali and Burkina Faso as well as other areas of West Africa.

     Women who are infibulated have to be cut open to allow sexual intercourse and more
cuts are needed for delivery of a child Wives, traditionally, are re-infibulated, for instance in
the Sudan, after the baby is born; and when the child is weaned, they are opened again for
intercourse. During her reproductive life, a woman used to go through this process with each
child; and in some areas it still continues today.

    In West Africa, infibulation is usually not done by sewing or other fastening devices; but,
by tying the legs of the girl together (after the operation) in a crossed position, the same
results are achieved. On a visit to Ouagadougou, Burkina Faso, in 1977, while I was at the
maternity hospital, a woman in labor with her first child was brought in; she could not deliver;
she was almost completely closed. There was nothing at all left of her external genitalia. She
had evidently conceived through a tiny opening.

    All the operations are performed on the ground, under septic conditions, with the same
knife or tool used on all the girls of a group operation, which is still the custom among many
ethnic groups in rural areas. In cases of fatalities, neither the operator nor the operation are
ever blamed. Rather, it is claimed that an evil spirit is responsible or the ritual was not
performed properly according to the wishes of the ancestors - or the girl herself is at fault
because she had sex before she was operated on.
     Infibulation or pharaonic circumcision is practiced in the Sudan and adjoining areas
throughout Somalia, parts of Ethiopia, Southern Egypt and Northern Kenya and in some
areas of West Africa, for instance, Mali. Infibulation or pharaonic circumcision is the most
drastic and damaging operation. It is called "Pharaonic" as the operation, according to
historic documents, was already recorded in ancient Egypt more than 2,000 years ago in
Pharaonic times.

     The term infibulation is derived from fibula, which means clasp or pin in Latin and goes
back to the old Romans; a fibula was used to hold together the folds of the toga - the loose
garment all Roman men wore. The Romans also fastened together the large lips of slave girls
to prevent them from having sexual intercourse as becoming pregnant would hamper their
work.

     Here is an eyewitness description of an operation in Somalia:

"With the Somalis, the circumcision of girls takes place in the home among women relatives and neighbors. The
grandmother or an older woman officiates. At each occasion, usually only one little girl or at times two sisters
are operated; but all girls, without exception, must undergo this mutilation as it is a requirement for marriage.

"The operation itself is not accompanied by any ceremony or ritual.

"The child, completely naked, is made to sit on a low stool. Several women take hold of her and open her legs
wide. After separating her outer and inner lips, the operator, usually a woman experienced in this procedure, sits
down facing the child. With her kitchen knife, the operator first pierces and slices open the hood of the clitoris.
Then she begins to cut it out. While another woman wipes off the blood with a rag, the operator digs with her
sharp fingernail a hole the length of the clitoris to detach and pull out the organ. The little girl, held down by the
women helpers, screams in extreme pain; but no one pays the slightest attention.

"The operator finishes this job by entirely pulling out the clitoris, cutting it to the bone with her knife. Her
helpers again wipe off the spurting blood with a rag. The operator then removes the remaining flesh, digging
with her finger to remove any remnant of the clitoris among the flowing blood. The neighbor women are then
invited to plunge their fingers into the bloody hole to verify that every piece of the clitoris is removed.

"But this is not the end. The most important part of the operation begins only now. After a short moment, the
woman takes the knife again and cuts off the inner lips (labia minor) of the victim. The helpers again wipe the
blood with their rags. Then the operator, with a motion of her knife, begins to scrape the skin from the inside of
the large lips.

"With the abrasion of the skin completed, according to the rules, the operator closes the bleeding large lips and
fixes them one against the other with long acacia thorns.

"At this stage of the operation, the child is so exhausted that she stops crying, but often has convulsions. The
women then force down her throat a concoction of plants.

"The operator's chief concern is to leave an opening no larger than a kernel of corn or just being enough to allow
urine, and later the menstrual flow, to pass. The family honor depends on making the opening as small as
possible because with Somalis, the smaller the artificial passage is, the greater the value of the girl and the
higher the bride price.

"When the operation is finished, the woman pours water over the genital area of the girl and wipes her with a
rag. Then the child, who was held down all this time, is made to stand up. The women then immobilize her
thighs by tying them together with ropes of goat skin. This bandage is applied from knees to the waist of the girl,
and is left in place for about two weeks. The girl must remain lying on a mat for the entire time, while all the
excrement evidently remains with her in the bandage.
"After that time, the girl is released and the bandage is cleaned. Her vagina is now closed, and remains so until
her marriage. Contrary to what one would assume, not many girls die from this torture. There are, or course,
various complications which frequently leave the girl crippled and disabled for the rest of her life."

    Many colorful myths are related all over Africa as reasons for the operations. Though all
the myths are still believed by the ethnic groups involved inn the rural areas, many of the
reasons are contradictory, and none of them are compatible with biological facts.

     Most Africans who practice these operations believe that excision is a custom decreed by
the ancestors; therefore, it must be complied with. Most often, men refuse to marry girls who
are not excised. Since marriage is still the only career for a woman in most of Africa and the
Middle East, the operations continue. "No proper Kikuyu would dream of marrying a girl
who has not been circumcised," stated Jomo Kenyatta, the revered leader of Kenya, in his
book, Facing Mount Kenya, which was written in the 1930s and continued to be published,
and is also sold in tourist shops in Nairobi.

    As President of Kenya for life, Kenyatta had great influence on Africans well beyond the
borders of Kenya, and his much quoted statement is responsible for the mutilation of many
thousands of helpless little girls and untold suffering and deaths.

    The successor of Kenyatta, President Arap Moi, categorically prohibited female genital
mutilation operations in 1982. He also alerted the Health Services that no more operations
may be done in hospitals, which shows that the Kenyan Health Services were involved in the
mutilations. Unfortunately, there has been no follow-up, teaching or educating the people
against the mutilations. As a result, they have gone underground.

     Excision, by cutting out the most sensitive tissues of a woman's body, extinguishes
sexual sensitivity, pleasure and response to touch. The elimination of female sexual pleasure
is the reason most frequently given for the genital mutilations, which is to keep "moral
behavior of women in society" and "to assure the faithfulness of women to their husbands" -
who usually have several wives. In many ethnic groups, for instance in Mali and
Francophone West Africa, the operation traditionally is performed just before marriage, as a
puberty rite; it is claimed that a woman can be accepted into adult society and get married
only after she is operated upon.

     In the Sudan and the Middle East, and in Moslem societies, for instance in Somalia, it is
said that a woman is incapable of controller her sexuality - hence she must be excised or
infibulated or she will disgrace her family. Women who do not have their genitals mutilated
are considered to be prostitutes.

     Excision is also perceived as a way to increase fertility; and the wish of most women is
to have as many children as possible, especially sons, on which their status in society depends.
The biological facts about reproduction are unknown or ignored. It is widely believed, for
instance, in Mali and Burkino Faso, and all over West Africa, that the clitoris connotes
maleness, and the prepuce of the penis, femaleness. Hence, both have to be removed before a
person can be accepted as an adult in his/her sex and society. It is also believed that a girl
who is not operated on will run wild and disgrace her family. In Egypt, aesthetic reasons are
sometimes cited for the operation, and this is occasionally said in other areas of Africa as
well. It is said that women's external genitalia are ugly and must be removed to make her
acceptable to a man.
     Hypertrophy of the clitoris - by which is meant an unusual enlargement of the organ - is
cited as reason for excision in Ethiopia and also in parts of Nigeria. The Catholic Church has
sanctioned the genital mutilation of all female children of its converts on those grounds since
the 17th Century when the Pope sent a medical mission to Ethiopia.

    Health reasons are often cited, especially in urban areas where the traditional myths are
forgotten. Cleanliness is the reason given also by middle class women in areas as far apart as
Cairo and Bamako.

    Also, in Sudan, genital mutilations are connected with cleanliness and is called "Tahur,"
which in Arabic means purity. A woman is considered dirty and polluted unless she is
mutilation. The same is often said in Somalia.

     Many of the reasons given by local populations are quite similar, though they have been
arrived at quite independently, as no connection or communication exists between the
population groups involved. Most of these myths are promoted by men, which once more
documents the amazing world-wide similarity of male attitudes concerning female sexuality.

     Obviously, all of the myths are designed to justify and continue the female genital
mutilations, from which men derive power and control over women as a group. This is, of
course, the real reason why these operations continue today, and why they are being rapidly
introduced into the modern sector throughout the African continent with the collusion of
Western men, and especially the male-dominated health system. Though the social rites and
ceremonies are minimized or forgotten, the surgery continues: and a lot of money can be
made from this.

     The genital mutilations are now performed on much younger children especially in the
towns, as it is feared by men that the girls will resist once they go to school. Even in areas
where traditionally the operations were a coming-of-age custom, they are now done on very
young children, sometimes a few years old, or even shortly after birth. The stated purpose of
the operation - introduction to adult life - has disappeared. Nevertheless, the mutilations
continue to be practiced even in families of government officials and political leaders where
many of the men have been to European or Western universities. The reasons given by these
men are "tradition" - yet the men have rejected all African traditions for their own
Westernized personal lives.

     The patriarchal family structure and ideology of male supremacy supported by religion
provides the underpinning for genital mutilations both past and present. It is well recognized
that religious beliefs are invariably cited to support the "necessity" for having the genitals of
daughters excised and/or infibulated. The operations are practiced by animists - those who
believe in ancestor worship - stating that "the ancestors decreed these operations and their
wishes must be followed.

      They are practiced by Moslems - indeed in the Sudan and also in West Africa the local
sheiks and marabouts claim that excision or infibulation is a required or "preferable" Moslem
rite. But Egyptian Moslem religious authorities at the recognized El Azhar University state
there is no requirement for female genital mutilation in the Koran. Male circumcision,
however, is an absolute command.
     Excision and infibulation are practiced by Christians of all denominations. As stated
earlier, the Papacy of the Roman Catholic Church has officially supported the genital
mutilations every since a medical mission was sent from Rome to Ethiopia in the 18th
Century which declared that genital mutilations are "necessary."

     The followers of the Ethiopian Christian Church and the Copts in Egypt (more than
seven million adherents) have always mutilated the genitals of their female children. Indeed,
all religions (with the exception of the Scottish Protestant Church in Kenya in the 1920s)
have actively supported or tolerated the mutilation of girls to make the pliable subjects of the
dominant patriarchal community that vests all rights in the males. There is no doubt that
genital mutilation does permanent life-long physical and psychological damage to women.
The full impact of the often terrible psychological consequences have never been
systematically investigated though it is known that numerous young women commit suicide,
as, for instance, reported in Burkina Faso.

     Patriarchal religions - there are no others in Africa/The Middle East - provide the
intellectual basis for men to keep their power and privileges in society. Who is going to
question "the holy religious beliefs" expressed by men? Certainly not women - the vast
majority in Africa and the Middle East are still illiterate (in some countries up to 90%). And
men from Western countries, especially those concerned with development, have been
warned by the militant male politicians to keep hands off their "culture," which in Africa and
the Middle East sanctions polygamy, wife beating (the diameter of the stick if specified in
some countries), the bride price (selling of young girls into marriage by their fathers),
unilateral divorce, child marriage and female genital mutilations.

     Over the centuries and due to their isolation, women have come to believe that the
mutilation of their genitals are "necessary." Indeed, many women think that they are done all
over the world. Thus, they are accepted as "natural." Some African women even now cannot
believe that the operations are not done in other parts of the world.

     The wholesale support of cultural traditions by anthropologists without critical
evaluations of the often terrible damage done to the most vulnerable members of each
community - children, especially female children and women - is completely irresponsible.
There is hardly a major development program in Africa by the U.S. Agency for International
Development - especially in health - that does not consult an anthropologist. I have frequently
run into those "development advisers" who impose their ethnocentric views on multimillion
dollar health programs in Africa. As a result, the terrible health damage done to girls and
women by traditional practices is ignored because it is the "culture." I testified repeatedly
before Congressional Committees - especially those concerned with appropriations for
Foreign Aid to attract attention to the health needs of women, especially in Africa, about the
modernization of female genital mutilations which are a violation of human rights.

     I stated in my Congressional testimony, "My research in Africa shows that genital
mutilations are increasingly performed in the modern sector in Africa, including hospitals,
often on small babies, stripped of all traditional rites. This is a gross abuse of modern
medicine. As Editor of WIN NEWS, I must advise this Committee that frequently health
equipment, tools and training contributed by the U.S. and other Western donors is used to
mutilate female children. Speaking for American women and tax-payers, I strenuously object
to the use of U.S. monies and contributions to carry out sexual castrations - that is,
clitoridectomies and infibulations - on non-consenting children in Africa and the Middle
East."

     The desire of modernization and especially all kinds of imported equipment and tools,
especially by men, provides a unique opportunity for men to teach their African brothers that
these genital mutilations are not acceptable. Only men can reach their African counterparts on
this subject - especially since sexuality is involved, to teach them the biological facts in a
persuasive way and from their own experience. Unfortunately, no one has ever really tried to
reach African men who make all the decisions in each family about the truth regarding
female genital mutilations. Men also have been left out where family planning programs are
concerned - which are all imported by Development and Population experts. As a result,
family planning in Africa has and is failing.

     It is up to the male development and health advisers and all those who have contact with
African men - for instance, the way many students from Africa at Western Universities - to
talk to them about excision and infibulation and to explain to them why these genital
mutilations are unacceptable. But unfortunately, such educational programs have not been
tried.

     African women have now started to organize to fight against these terrible genital
mutilations in a systematic way. The Inter-African Committee was created in 1984, five years
after the ground-breaking seminar, organized by WHO, on the "Traditional Practices
Affecting the Health of Women and Children" held in Khartoum, Sudan.

    As a temporary adviser to WHO - the sponsor of the meeting - I provided an overview of
female child genital mutilations around the globe. This meeting opened up the international
discussion on female genital mutilations, which had been a taboo subject until then. That was
in 1979. The seminar attracted world-wide attention with delegations and observers from the
health departments of nine African and Middle Eastern countries, as well as many Sudanese
physicians and health officials. Unfortunately, limited action followed this seminar.

   Four recommendations were unanimously voted by the delegates at the end of this fateful
meeting:

      Adoption of clear national policies for the abolishment of female circumcision;
      Establishment of national commissions to coordinate and follow up the activities of other
       bodies involved including, where appropriate, the enactment of legislation prohibiting
       female circumcision;
      Intensification of general education of the public, including health education at all levels,
       with special emphasis on the dangers and the undesirability of female circumcision;
      Intensification of education programs for traditional birth attendants, midwives, healers and
       other practitioners of traditional medicine, to demonstrate the harmful effects of female
       circumcision, with a view to enlisting their support along with general efforts to abolish this
       practice.

    The Inter-African Committee, formed in 1984 at an international meeting and headed by
Berhane Ras-Work, by now has affiliated National Committees in 14 African countries and
has offices in Addis Ababa (at the ECA - Economics Commission of Africa) and Geneva.
They held several overflow meetings at the 1985 U.N. Decade Conference for Women in
Nairobi and have published an "Action Plan" that provides an excellent set of guidelines for
the National Committees to follow - who have held meetings in many African countries.

    A ground-breaking International Seminar on "Strategies to Bring About Change" was
held in June 1988, in Mogadishu, to draw world attention to the Somalian Campaign to
Eradicate Infibulation - which was started two years ago.

     The SWDO (Somali Women's Democratic Organization), jointly with ADIoS (The
Italian Association for Women in Development) has organized a national campaign, fully
supported by the Somalian government, to eradicate these damaging traditional practices.
Indeed, every department of the Somalian government is involved in this national initiative
led by the outspoken president of the SWDO, Muraio Garad Ahmed, who wields
considerable political power.

    AIDos, led by Daniela Colombo and with the assistance of the Italian government, has
worked jointly with the SWDO in Somalia to develop viable strategies and extensive
teaching aids for all different kinds of programs addressed to different sectors of the
population.

      The secrecy surrounding infibulation has only recently begun to be lifted in Somalia. It
took considerable courage for the SWDO to take up this issue. Thanks to the perseverance of
its leadership, it now has become a national campaign supported not only by the health
ministry, but also by all other ministries, especially education. The campaign to eradicate
female child genital mutilation is going on in all the schools; it is discussed on the radio and
TV. Indeed, no occasion is missed to create awareness among the population about the
damage done by infibulation. All families are urged to stop having their daughters "done."

     This international seminar had been preceded by a national meeting which had developed
a program of action for the joint SWDO-AIDoS Information Campaign. At the international
seminar in Mogadishu, many influential national and international leaders gave speeches at
the opening and closing sessions in the great hall of the Parliament. The speakers included a
representative of the President of Somalia, the Minister of Health, The SWDO President, the
Italian Ambassador, representatives of UNICEF, WHO, AIDoS and others.

     Delegates from several African countries, including Egypt, Sudan, The Gambia and
Nigeria presented outlines about the successful campaigns and strategies to eradicate female
child genital mutilations in their countries. Egypt, with a program sponsored by the Cairo
Family Planning Association, led by Aziza Kamel, has the most extensive experience in
conducting a multitude of successful grassroots initiatives. From London, Stella Efua Graham,
a native of Ghana and President of FORWARD (the Forward), outlined her educational work
among African immigrants to the U.K. A doctor from Indonesia discussed how female
circumcision in Indonesia had now been changed into a purely symbolic rite. Berhane Ras
Work, the president of the Inter-African Committee (IAC) on "Traditional Practices
Affecting the Health of Women and Children" founded in 1984, talked about its work all over
Africa.

    Women's International Network (WIN) was represented at the seminar by Fran P.
Hosken, who spoke about the actions against female child genital mutilations all over the
world, and about the Universal Childbirth Picture Books, with additions to prevent excision
and infibulation that WIN has developed and introduced all over Africa with much success.
The books are currently being translated.

RESOURCE LIST:

Women's International Network News (WIN News), publishes a column of "Female Circumcision/Genital
and Sexual Mutilation" in every issue (quarterly) since 1975, where infromation - including names and
addresses - contacts are reported from all over the world. For subscriptions write to WIN NEWS, 187 Grant St.,
Lexington, MA 02173

The Hosken Report: Genital/Sexual Mutilation of Females by Fran P. Hosken (Third Revised and Updated
Edition), Published By WIN news, Winter 1982/83, 344 pages with case histories from:
Sudan/Egypt/Somalia/Kenya/Ethiopia/Nigeria/Mali/Upper Volta/Ivory coast/Senegal/Sierra Leone/Arab
Penisula. Asual: Malaysia/Indonesia. The Western World.

Female Genital Mutilation in the World Today: A Global Review, by Fran P. Hosken, International Journal
of Health Services, Editor-in-Chief: Vincente Navarro, Johns Hopkins University, Baywood Publishing Co.,
120 Marine St., P.O. Box D, Farmingdale, NY 11735 (Vol 11, No. 3, 1981, pp. 415-530).

The Childbirth Picture Books, by Fran P. Hosken, pictures by Marcia L. Williams, published by WIN News,
187 Grant St., Lexington, MA 02173. Available in English/French/Arabic with Additions to Pernent Excision
and Infibulation/ and Spanish. Printed in India by CHETNA, 2nd Floor, Drive-in Cinema Buliding, Thaltej
Road, Admedabad 380 054, in Hindi and other Indian Languages.

Inter-African Committee, Africa Hall, Room 605, P.O. Box 3001, Addis Ababa, Ethiopia. Or: 147 rue de
Lausanne, CH-1202, Geneva, Switzerland. A Newspaper is available in English or French (2x year).

				
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