Female genital mutilation

English

Until the 1980s FGM was widely known as female circumcision, implying an equivalence in severity with male circumcision. From 1929 the Kenya Missionary Council referred to it as the sexual mutilation of women, following the lead of Marion Scott Stevenson, a Church of Scotland missionary. References to the practice as mutilation increased throughout the 1970s. In 1975 Rose Oldfield Hayes, an American anthropologist, used the term female genital mutilation in the title of a paper, and four years later Fran Hosken, an Austrian-American feminist writer, called it mutilation in her influential The Hosken Report: Genital and Sexual Mutilation of Females.

The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children and the World Health Organization (WHO) began referring to it as female genital mutilation in 1990 and 1991 respectively. Other terms used include female genital cutting (FGC) and female genital mutilation/cutting (FGM/C), preferred by those who work with practitioners.

Local terms

The many variants of FGM are reflected in dozens of terms in countries where it is common. These often refer to purification. In the Bambara language, spoken mostly in Mali, FGM is known as bolokoli ("washing your hands") and in the Igbo language in eastern Nigeria as isa aru or iwu aru ("having your bath"). A common Arabic term for purification has the root t-h-r, used for male and female circumcision (tahur and tahara). It is also known in Arabic as khafḍ or khifaḍ.

Communities may refer to only two forms of FGM: "pharaonic" for infibulation and sunna circumcision for everything else. Sunna means "path or way" in Arabic and refers to the tradition of Muhammad, although none of the procedures are required within Islam. The term infibulation derives from fibula, Latin for clasp; the Ancient Romans reportedly fastened clasps through the foreskins or labia of slaves to prevent sexual intercourse. The surgical infibulation of women came to be known as pharaonic circumcision in Sudan, but as Sudanese circumcision in Egypt. In Somalia it is known simply as qodob ("to sew up").

Methods

The procedures are generally performed by a traditional circumciser (cutter or exciseuse) in the girls' homes, with or without anaesthesia. The cutter is usually an older woman, but in communities where the male barber has assumed the role of health worker he will perform FGM too.

When traditional cutters are involved, non-sterile devices are likely to be used, including knives, razors, scissors, glass, sharpened rocks and fingernails. According to a nurse in Uganda, quoted in 2007 in The Lancet, a cutter would use one knife on up to 30 girls at a time.

Health professionals are often involved in Egypt, Kenya, Indonesia and Sudan. In Egypt 77 percent of FGM procedures, and in Indonesia over 50 percent, were performed by medical professionals as of 2008 and 2016. Women in Egypt reported in 1995 that a local anaesthetic had been used on their daughters in 60 percent of cases, a general anaesthetic in 13 percent and neither in 25 percent (two percent were missing/don't know).

Surveys, UN typology

The WHO, UNICEF and UNFPA issued a joint statement in 1997 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." The procedures vary considerably according to ethnicity and individual practitioners. During a 1998 survey in Niger, women responded with over 50 different terms when asked what was done to them. Translation problems are compounded by the women's confusion over which type of FGM they experienced, or even whether they experienced it. Several studies have suggested that survey responses are unreliable.

Standard questionnaires from United Nations bodies ask women whether they or their daughters have undergone the following: (1) cut, no flesh removed (pricking or symbolic circumcision); (2) cut, some flesh removed; (3) sewn closed; or (4) type not determined/unsure/doesn't know. The most common procedures fall within the "cut, some flesh removed" category and involve complete or partial removal of the clitoral glans.

WHO Types I–II

The World Health Organization created a more detailed typology. Types I–III vary in how much tissue is removed (Type III is the UNICEF category "sewn closed"). Type IV describes miscellaneous procedures, including symbolic circumcision.

Type Ia (circumcision) involves removal of the clitoral hood only and is rarely performed alone. The more common procedure is Type Ib (clitoridectomy), the complete or partial removal of the clitoral glans (the visible tip of the clitoris) and clitoral hood. The circumciser pulls the clitoral glans with her thumb and index finger and cuts it off.

Type II (excision) is the complete or partial removal of the inner labia, with or without removal of the clitoral glans and outer labia. Type IIa is removal of the inner labia; IIb, removal of the clitoral glans and inner labia; and IIc, removal of the clitoral glans, inner and outer labia. Excision in French can refer to any form of FGM.

Type III

Type III (infibulation or pharaonic circumcision), the "sewn closed" category, involves the removal of the external genitalia and fusion of the wound. The inner and/or outer labia are cut away, with or without removal of the clitoral glans. Type IIIa is the removal and closure of the inner labia and IIIb the outer labia. The practice is found largely in Djibouti, Eritrea, Ethiopia, Somalia and Sudan (though not South Sudan) in northeast Africa. Estimates of numbers vary: according to one in 2008, over eight million women in Africa have experienced it. According to UNFPA in 2010, 20 percent of women with FGM have been infibulated.

Comfort Momoh, a specialist midwife, describes Type III: "[E]lderly women, relatives and friends secure the girl in the lithotomy position. A deep incision is made rapidly on either side from the root of the clitoris to the fourchette, and a single cut of the razor excises the clitoris and both the labia majora and labia minora." Girls "may be pinned down so firmly that bones may fracture". In Somalia the clitoral glans is removed and shown to the senior female relatives, who decide whether enough has been amputated. After this the labia are removed. The amputated parts might be placed in a pouch for the girl to wear.

A single hole of 2–3 mm is left for the passage of urine and menstrual fluid by inserting something, such as a twig, into the wound. The vulva is then closed with surgical thread, agave or acacia thorns, or covered with a poultice such as raw egg, herbs and sugar. To help the tissue bond, the girl's legs are tied together, often from hip to ankle; the bindings are usually loosened after a week and removed after two to six weeks. The result is a "drum of skin extending across the [vaginal] orifice except for a small hole," Momoh writes.

If the remaining hole is too large in the view of the girl's family, the procedure is repeated. The vagina is opened for sexual intercourse, for the first time either by a midwife with a knife or by the woman's husband with his penis. In some areas, including Somaliland, female relatives of the bride and groom might watch the opening of the vagina to check that the girl is a virgin. Psychologist Hanny Lightfoot-Klein interviewed hundreds of women and men in Sudan in the 1980s about sexual intercourse with Type III:

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 (in my study over 15%), and the task is often accomplished by a midwife under conditions of great secrecy, since this reflects negatively on the man's potency. Some who are unable to penetrate their wives manage to get them pregnant in spite of the infibulation, and the woman's vaginal passage is then cut open to allow birth to take place. ... Those men who do manage to penetrate their wives do so often, or perhaps always, with the help of the "little knife." This creates a tear which they gradually rip more and more until the opening is sufficient to admit the penis.

The woman is opened further for childbirth and closed afterwards, a process known as defibulation (or deinfibulation) and reinfibulation. Reinfibulation can involve cutting the vagina again to restore the pinhole size of the first infibulation. This might be performed before marriage, and after childbirth, divorce and widowhood.

Type IV

The WHO defines Type IV as "[a]ll other harmful procedures to the female genitalia for non-medical purposes", including pricking, piercing, incising, scraping and cauterization. It includes nicking of the clitoris (symbolic circumcision), burning or scarring the genitals, and introducing substances into the vagina to tighten it. Labia stretching is also categorized as Type IV. Common in southern and eastern Africa, the practice is supposed to enhance sexual pleasure for the man and add to the sense of a woman as a closed space. From the age of eight, girls are encouraged to stretch their inner labia using sticks and massage. Girls in Uganda are told they may have difficulty giving birth without stretched labia.

A definition of FGM from the WHO in 1995 included gishiri cutting and angurya cutting, found in Nigeria and Niger. These were removed from the WHO's 2008 definition because of insufficient information about prevalence and consequences. Angurya cutting is excision of the hymen, usually performed seven days after birth. Gishiri cutting involves cutting the vagina's front or back wall with a blade or penknife, performed in response to infertility, obstructed labour and other conditions. In a study by Nigerian physician Mairo Usman Mandara, over 30 percent of women with gishiri cuts were found to have vesicovaginal fistulae (holes that allow urine to seep into the vagina).

Short-term and late

FGM harms women's physical and emotional health throughout their lives. It has no known health benefits. The short-term and late complications depend on the type of FGM, whether the practitioner had medical training, and whether she used antibiotics and unsterilized or surgical single-use instruments. In the case of Type III, other factors include how small a hole was left for the passage of urine and menstrual blood, whether surgical thread was used instead of agave or acacia thorns, and whether the procedure was performed more than once (for example, to close an opening regarded as too wide or re-open one too small).

Common short-term complications include swelling, excessive bleeding, pain, urine retention and healing problems/wound infection. A 2015 systematic review of 56 studies that recorded immediate complications suggested that each of these occurred in more than one in ten girls and women undergoing any form of FGM, including symbolic nicking of the clitoris (Type IV), although the risks increased with Type III. The review also suggested that there was under-reporting. Other short-term complications include fatal bleeding, anaemia, urinary infection, septicaemia, tetanus, gangrene, necrotizing fasciitis (flesh-eating disease) and endometritis. It is not known how many girls and women die as a result of the practice, because complications may not be recognized or reported. The practitioners' use of shared instruments is thought to aid the transmission of hepatitis B, hepatitis C and HIV, although no epidemiological studies have shown this.

Late complications vary depending on the type of FGM. They include the formation of scars and keloids that lead to strictures and obstruction, epidermoid cysts that may become infected, and neuroma formation (growth of nerve tissue) involving nerves that supplied the clitoris.

An infibulated girl may be left with an opening as small as 2–3 mm, which can cause prolonged, drop-by-drop urination, pain while urinating, and a feeling of needing to urinate all the time. Urine may collect underneath the scar, leaving the area under the skin constantly wet, which can lead to infection and the formation of small stones. The opening is larger in women who are sexually active or have given birth by vaginal delivery, but the urethra opening may still be obstructed by scar tissue. Vesicovaginal or rectovaginal fistulae can develop (holes that allow urine or faeces to seep into the vagina). This and other damage to the urethra and bladder can lead to infections and incontinence, pain during sexual intercourse and infertility.

Painful periods are common because of the obstruction to the menstrual flow, and blood can stagnate in the vagina and uterus. Complete obstruction of the vagina can result in hematocolpos and hematometra (where the vagina and uterus fill with menstrual blood). The swelling of the abdomen that results from the collection of fluid, together with the lack of menstruation, can lead to suspicion of pregnancy. Asma El Dareer, a Sudanese physician, reported in 1979 that a girl in Sudan with this condition was killed by her family.

Pregnancy, childbirth

FGM may place women at higher risk of problems during pregnancy and childbirth, which are more common with the more extensive FGM procedures. Infibulated women may try to make childbirth easier by eating less during pregnancy to reduce the baby's size. In women with vesicovaginal or rectovaginal fistulae, it is difficult to obtain clear urine samples as part of prenatal care, making the diagnosis of conditions such as pre-eclampsia harder. Cervical evaluation during labour may be impeded and labour prolonged or obstructed. Third-degree laceration (tears), anal-sphincter damage and emergency caesarean section are more common in infibulated women.

Neonatal mortality is increased. The WHO estimated in 2006 that an additional 10–20 babies die per 1,000 deliveries as a result of FGM. The estimate was based on a study conducted on 28,393 women attending delivery wards at 28 obstetric centres in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan. In those settings all types of FGM were found to pose an increased risk of death to the baby: 15 percent higher for Type I, 32 percent for Type II and 55 percent for Type III. The reasons for this were unclear, but may be connected to genital and urinary tract infections and the presence of scar tissue. The researchers wrote that FGM was associated with an increased risk to the mother of damage to the perineum and excessive blood loss, as well as a need to resuscitate the baby, and stillbirth, perhaps because of a long second stage of labour.

Psychological effects, sexual function

According to a 2015 systematic review there is little high-quality information available on the psychological effects of FGM. Several small studies have concluded that women with FGM suffer from anxiety, depression and post-traumatic stress disorder. Feelings of shame and betrayal can develop when women leave the culture that practises FGM and learn that their condition is not the norm, but within the practising culture they may view their FGM with pride, because for them it signifies beauty, respect for tradition, chastity and hygiene.

Studies on sexual function have also been small. A 2013 meta-analysis of 15 studies involving 12,671 women from seven countries concluded that women with FGM were twice as likely to report no sexual desire and 52 percent more likely to report dyspareunia (painful sexual intercourse). One third reported reduced sexual feelings.

Household surveys

The prevalence of FGM is defined as the percentage of the 15–49 age group that has exerienced it. These figures are based on nationally representative household surveys known as Demographic and Health Surveys (DHS), developed by Macro International and funded mainly by the United States Agency for International Development (USAID), and Multiple Indicator Cluster Surveys (MICS), conducted with financial and technical help from UNICEF.

These surveys have been carried out in Africa, Asia, Latin America and elsewhere roughly every five years, since 1984 and 1995 respectively. The first to ask about FGM was the 1989–1990 DHS in northern Sudan. The first publication to estimate FGM prevalence based on DHS data (in seven countries) was by Dara Carr of Macro International in 1997.

Prevalence

FGM is found mostly in what Gerry Mackie called an "intriguingly contiguous" zone in Africa—east to west from Somalia to Senegal, and north to south from Egypt to Tanzania. Nationally representative figures are available for 27 countries in Africa, as well as Indonesia, Iraqi Kurdistan and Yemen. Over 200 million women and girls are thought to be living with FGM in those 30 countries.

The highest concentrations among the 15–49 age group are in Somalia (98 percent), Guinea (97 percent), Djibouti (93 percent), Egypt (91 percent) and Sierra Leone (90 percent). As of 2013, 27.2 million women had undergone FGM in Egypt, 23.8 million in Ethiopia, and 19.9 million in Nigeria. There is also a high concentration in Indonesia, where Type Ia (removal of the clitoral hood) and symbolic nicking (Type IV) are practised; the prevalence rate for the 0–11 group is 49 percent (13.4 million).

Smaller studies or anecdotal reports suggest that FGM is also practised in Colombia, the Congo, Malaysia, Oman, Peru, Saudi Arabia, Sri Lanka, and the United Arab Emirates, as well as among the Bedouin in Israel; in Rahmah, Jordan; and among the Dawoodi Bohra in India. It is also found within immigrant communities in Australasia, Europe, North America and Scandinavia.

Downward trend

Prevalence figures for the 15–19 age group and younger show a downward trend. For example, Burkina Faso fell from 89 percent (1980) to 58 percent (2010); Egypt from 97 percent (1985) to 70 percent (2015); and Kenya from 41 percent (1984) to 11 percent (2014).

From 2010 household surveys asked women about the FGM status of all their living daughters. The highest concentrations among girls aged 0–14 were in Gambia (56 percent), Mauritania (54 percent), Indonesia (49 percent for 0–11) and Guinea (46 percent). The figures suggest that a girl was one third less likely in 2014 to undergo FGM than she was 30 years ago. If the rate of decline continues, the number of girls cut will nevertheless rise from 3.6 million a year in 2013 to 4.1 million in 2050 because of population growth.

Rural areas, wealth, education

Surveys have found FGM to be more common in rural areas, less common in most countries among girls from the wealthiest homes, and (except in Sudan and Somalia) less common in girls whose mothers had access to primary or secondary/higher education. In Somalia and Sudan the situation was reversed: in Somalia the mothers' access to secondary/higher education was accompanied by a rise in prevalence of FGM in their daughters, and in Sudan access to any education was accompanied by a rise.

Age conducted

FGM is not invariably a rite of passage between childhood and adulthood, but is often performed on much younger children. Girls are most commonly cut shortly after birth to age 15. In half the countries for which national figures were available in 2000–2010, most girls had been cut by age five.

Over 80 percent (of those cut) are cut before the age of five in Nigeria, Mali, Eritrea, Ghana and Mauritania. The 1997 Demographic and Health Survey in Yemen found that 76 percent of girls had been cut within two weeks of birth. The percentage is reversed in Somalia, Egypt, Chad and the Central African Republic, where over 80 percent (of those cut) are cut between five and 14. Just as the type of FGM is often linked to ethnicity, so is the mean age. In Kenya, for example, the Kisi cut around age 10 and the Kamba at 16.

Ethnicity

A country's national prevalence often reflects a high sub-national prevalence among certain ethnicities, rather than a widespread practice. In Iraq, for example, FGM is found mostly among the Kurds in Erbil (58 percent prevalence within age group 15–49, as of 2011), Sulaymaniyah (54 percent) and Kirkuk (20 percent), giving the country a national prevalence of eight percent.

The practice is sometimes an ethnic marker, but may differ along national lines. In the northeastern regions of Ethiopia and Kenya, which share a border with Somalia, the Somali people practise FGM at around the same rate as they do in Somalia. But in Guinea all Fulani women responding to a survey in 2012 said they had experienced FGM, against 12 percent of the Fulani in Chad, while in Nigeria the Fulani are the only large ethnic group in the country not to practise it.

Type of FGM

Women are asked during surveys about the type of FGM they experienced:

Most women report "cut, some flesh removed" (Types I and II). According to Mackie in 2003, Type II is more common in Egypt, while a 2011 study identified Type I as more common. In Nigeria Type I is usually found in the south and the more severe forms in the north.

Type III (infibulation) is concentrated in northeastern Africa, particularly Djibouti, Eritrea, Somalia and Sudan. In surveys in 2002–2006, 30 percent of cut girls in Djibouti, 38 percent in Eritrea, and 63 percent in Somalia had experienced Type III. There is also a high prevalence of infibulation among girls in Niger and Senegal, and in 2013 it was estimated that in Nigeria three percent of the 0–14 age group had been infibulated. The type of procedure is often linked to ethnicity. In Eritrea, for example, a survey in 2002 found that all Hedareb girls had been infibulated, compared with two percent of the Tigrinya, most of whom fell into the "cut, no flesh removed" category.

Support for this practice in Africa comes predominantly from women.

Dahabo Musa, a Somali woman, described infibulation in a 1988 poem as the "three feminine sorrows": the procedure itself, the wedding night when the woman is cut open, then childbirth when she is cut again. Despite the evident suffering, it is women who organize all forms of FGM. Anthropologist Rose Oldfield Hayes wrote in 1975 that educated Sudanese men who did not want their daughters to be infibulated (preferring clitoridectomy) would find the girls had been sewn up after the grandmothers arranged a visit to relatives.

Gerry Mackie has compared FGM to footbinding. Like FGM, footbinding was carried out on young girls, nearly universal where practised, tied to ideas about honour, chastity and appropriate marriage, and supported by women. FGM practitioners see the procedures as marking not only ethnic boundaries but also gender difference. According to this view, FGM demasculinizes women, while male circumcision defeminizes men.

Fuambai Ahmadu, an anthropologist and member of the Kono people of Sierra Leone, who in 1992 underwent clitoridectomy as an adult during a Sande society initiation, argued in 2000 that it is a male-centred assumption that the clitoris is important to female sexuality. African female symbolism revolves instead around the concept of the womb. Infibulation draws on that idea of enclosure and fertility. "[G]enital cutting completes the social definition of a child's sex by eliminating external traces of androgyny," Janice Boddy wrote in 2007. "The female body is then covered, closed, and its productive blood bound within; the male body is unveiled, opened and exposed."

In communities where infibulation is common, there is a preference for women's genitals to be smooth, dry and without odour, and both women and men may find the natural vulva repulsive. Men seem to enjoy the effort of penetrating an infibulation. The local preference for dry sex causes women to introduce substances into the vagina to reduce lubrication, including leaves, tree bark, toothpaste and Vicks menthol rub. The WHO includes this practice within Type IV FGM, because the added friction during intercourse can cause lacerations and increase the risk of infection. Because of the smooth appearance of an infibulated vulva, there is also a belief that infibulation increases hygiene.

Common reasons for FGM cited by women in surveys are social acceptance, religion, hygiene, preservation of virginity, marriageability and enhancement of male sexual pleasure. In a study in northern Sudan, published in 1983, only 17.4 percent of women opposed FGM (558 out of 3,210), and most preferred excision and infibulation over clitoridectomy. Attitudes are changing slowly. In Sudan in 2010, 42 percent of women who had heard of FGM said the practice should continue. In several surveys since 2006, over 50 percent of women in Mali, Guinea, Sierra Leone, Somalia, Gambia and Egypt supported FGM's continuance, while elsewhere in Africa, Iraq and Yemen most said it should end, although in several countries only by a narrow margin.

Social obligation, poor access to information

Against the argument that women willingly choose FGM for their daughters, UNICEF calls the practice a "self-enforcing social convention" to which families feel they must conform to avoid uncut daughters facing social exclusion.

Ellen Gruenbaum reports that, in Sudan in the 1970s, cut girls from an Arab ethnic group would mock uncut Zabarma girls with Ya, Ghalfa! ("Hey, unclean!"). The Zabarma girls would respond Ya, mutmura! (A mutmara was a storage pit for grain that was continually opened and closed, like an infibulated woman.) But despite throwing the insult back, the Zabarma girls would ask their mothers, "What's the matter? Don't we have razor blades like the Arabs?"

Because of poor access to information, and because circumcisers downplay the causal connection, women may not associate the health consequences with the procedure. Lala Baldé, president of a women's association in Medina Cherif, a village in Senegal, told Mackie in 1998 that when girls fell ill or died, it was attributed to evil spirits. When informed of the causal relationship between FGM and ill health, Mackie wrote, the women broke down and wept. Mackie argued that surveys taken before and after this sharing of information would show very different levels of support for FGM.

The American non-profit group Tostan, founded by Molly Melching in 1991, introduced community-empowerment programmes in several countries that focus on local democracy, literacy, and education about healthcare, giving women the tools to make their own decisions. In 1997, using the Tostan programme, Malicounda Bambara in Senegal became the first village to abandon FGM. By 2016, over 7,300 communities in six countries had pledged to abandon FGM and child marriage.

Religion

Surveys have shown a widespread belief, particularly in Mali, Mauritania, Guinea and Egypt, that FGM is a religious requirement. Gruenbaum has argued that practitioners may not distinguish between religion, tradition and chastity, making it difficult to interpret the data.

FGM's origins in northeastern Africa are pre-Islamic, but the practice became associated with Islam because of that religion's focus on female chastity and seclusion. There is no mention of it in the Quran. It is praised in several hadith (sayings attributed to Muhammad) as noble but not required. In 2007 the Al-Azhar Supreme Council of Islamic Research in Cairo ruled that FGM had "no basis in core Islamic law or any of its partial provisions."

There is no mention of FGM in the Bible. Christian missionaries in Africa were among the first to object to FGM, but Christian communities in Africa do practise it. A 2013 UNICEF report identifies 17 African countries where at least 10 percent of Christian girls and women aged 15 to 49 years have undergone FGM. The only Jewish group known to have practised it are the Beta Israel of Ethiopia. Judaism requires male circumcision, but does not allow FGM. FGM is also practised by animist groups, particularly in Guinea and Mali.

Antiquity

The practice's origins are unknown, but its east-west, north-south distribution in Africa meets in Sudan. Gerry Mackie has suggested that infibulation began there with the Meroite civilization (c. 800 BCE – c. 350 CE), before the rise of Islam, to increase confidence in paternity. According to historian Mary Knight, Spell 1117 (c. 1991–1786 BCE) of the Ancient Egyptian Coffin Texts may refer in hieroglyphs to an uncircumcised girl ('m't):

The spell was found on the sarcophagus of Sit-hedjhotep, now in the Egyptian Museum, and dates to Egypt's Middle Kingdom. (Paul F. O'Rourke argues that 'm't probably refers instead to a menstruating woman.) The proposed circumcision of an Egyptian girl, Tathemis, is also mentioned on a Greek papyrus, from 163 BCE, in the British Museum:

Sometime after this, Nephoris [Tathemis's mother] defrauded me, being anxious that it was time for Tathemis to be circumcised, as is the custom among the Egyptians. She asked that I give her 1,300 drachmae ... to clothe her ... and to provide her with a marriage dowry ... if she didn't do each of these or if she did not circumcise Tathemis in the month of Mecheir, year 18 [163 BCE], she would repay me 2,400 drachmae on the spot.

The examination of mummies has shown no evidence of FGM. Citing the Australian pathologist Grafton Elliot Smith, who examined hundreds of mummies in the early 20th century, Knight writes that the genital area may resemble Type III because during mummification the skin of the outer labia was pulled toward the anus to cover the pudendal cleft, possibly to prevent sexual violation. It was similarly not possible to determine whether Types I or II had been performed, because soft tissues had deteriorated or been removed by the embalmers.

The Greek geographer Strabo (c. 64 BCE – c. 23 CE) wrote about FGM after visiting Egypt around 25 BCE (right). The philosopher Philo of Alexandria (c. 20 BCE – 50 CE) also made reference to it: "the Egyptians by the custom of their country circumcise the marriageable youth and maid in the fourteenth (year) of their age, when the male begins to get seed, and the female to have a menstrual flow." It is mentioned briefly in a work attributed to the Greek physician Galen (129 – c. 200 CE): "When [the clitoris] sticks out to a great extent in their young women, Egyptians consider it appropriate to cut it out."

Another Greek physician, Aëtius of Amida (mid-5th to mid-6th century CE), offered more detail in book 16 of his Sixteen Books on Medicine, citing the physician Philomenes. The procedure was performed in case the clitoris, or nymphê, grew too large or triggered sexual desire when rubbing against clothing. "On this account, it seemed proper to the Egyptians to remove it before it became greatly enlarged", Aëtius wrote, "especially at that time when the girls were about to be married":

The surgery is performed in this way: Have the girl sit on a chair while a muscled young man standing behind her places his arms below the girl's thighs. Have him separate and steady her legs and whole body. Standing in front and taking hold of the clitoris with a broad-mouthed forceps in his left hand, the surgeon stretches it outward, while with the right hand, he cuts it off at the point next to the pincers of the forceps.

The genital area was then cleaned with a sponge, frankincense powder and wine or cold water, and wrapped in linen bandages dipped in vinegar, until the seventh day when calamine, rose petals, date pits or a "genital powder made from baked clay" might be applied.

Whatever the practice's origins, infibulation became linked to slavery. Mackie cites the Portuguese missionary João dos Santos, who in 1609 wrote of a group inland from Mogadishu who had a "custome to sew up their Females, especially their slaves being young to make them unable for conception, which makes these slaves sell dearer, both for their chastitie, and for better confidence which their Masters put in them." The English explorer William Browne wrote in 1799 that the Egyptians practised excision, and that slaves in that country were infibulated to prevent pregnancy. Thus, Mackie argues, a "practice associated with shameful female slavery came to stand for honor."

Europe and the United States

Gynaecologists in 19th-century Europe and the United States removed the clitoris to treat insanity and masturbation. British doctor Robert Thomas suggested clitoridectomy as a cure for nymphomania in 1813. The first reported clitoridectomy in the West, described in The Lancet in 1825, was performed in 1822 in Berlin by Karl Ferdinand von Graefe on a 15-year-old girl who was masturbating excessively.

Isaac Baker Brown, an English gynaecologist, president of the Medical Society of London, and co-founder in 1845 of St. Mary's Hospital there, believed that masturbation, or "unnatural irritation" of the clitoris, caused hysteria, spinal irritation, fits, idiocy, mania and death. He therefore "set to work to remove the clitoris whenever he had the opportunity of doing so", according to his obituary in the Medical Times and Gazette in 1873. Brown performed several clitoridectomies between 1859 and 1866. When he published his views in On the Curability of Certain Forms of Insanity, Epilepsy, Catalepsy, and Hysteria in Females (1866), doctors in London accused him of quackery and expelled him from the Obstetrical Society.

In the United States J. Marion Sims followed Brown's work, and in 1862 slit the neck of a woman's uterus and amputated her clitoris, "for the relief of the nervous or hysterical condition as recommended by Baker Brown", after the patient complained of menstrual pain, convulsions and bladder problems. Later that century A. J. Bloch, a surgeon in New Orleans, removed the clitoris of a two-year-old girl who was reportedly masturbating. According to a 1985 paper in the Obstetrical & Gynecological Survey, clitoridectomy was performed in the US into the 1960s to treat hysteria, erotomania and lesbianism.

Colonial opposition in Kenya

Protestant missionaries in British East Africa (present-day Kenya) began campaigning against FGM in the early 20th century, when Dr. John Arthur joined the Church of Scotland Mission (CSM) in Kikuyu. An important ethnic marker, the practice was known by the Kikuyu, the country's main ethnic group, as irua for both girls and boys. It involved excision (Type II) for girls and removal of the foreskin for boys. Unexcised Kikuyu women (irugu) were outcasts.

Jomo Kenyatta, general secretary of the Kikuyu Central Association and Kenya's first prime minister from 1963, wrote in 1938 that, for the Kikuyu, the institution of FGM was the "conditio sine qua non of the whole teaching of tribal law, religion and morality." No proper Kikuyu man or woman would marry or have sexual relations with someone who was not circumcised. A woman's responsibilities toward the tribe began with her initiation. Her age and place within tribal history was traced to that day, and the group of girls with whom she was cut was named according to current events, an oral tradition that allowed the Kikuyu to track people and events going back hundreds of years.

Beginning with the CSM mission in 1925, several missionary churches declared that FGM was prohibited for African Christians. The CSM announced that Africans practising it would be excommunicated, which resulted in hundreds leaving or being expelled. The stand-off turned FGM into a focal point of the Kenyan independence movement; the 1929–1931 period is known in the country's historiography as the female circumcision controversy.

In 1929 the Kenya Missionary Council began referring to FGM as the "sexual mutilation of women", rather than circumcision, and a person's stance toward the practice became a test of loyalty, either to the Christian churches or to the Kikuyu Central Association. Hulda Stumpf, an American missionary with the Africa Inland Mission who opposed FGM in the girls' school she helped to run, was murdered in 1930. Edward Grigg, the governor of Kenya, told the British Colonial Office that the killer, who was never identified, had tried to circumcise her.

In 1956 the council of male elders (the Njuri Nchecke) in Meru announced a ban on FGM. Over the next three years, thousands of girls cut each other's genitals with razor blades as a symbol of defiance. The movement came to be known as Ngaitana ("I will circumcise myself"), because to avoid naming their friends the girls said they had cut themselves. Historian Lynn Thomas described the episode as significant in the history of FGM because it made clear that its victims were also its perpetrators.

Growth of opposition

The first known non-colonial campaign against FGM began in Egypt in the 1920s, when the Egyptian Doctors' Society called for a ban. There was a parallel campaign in Sudan, run by religious leaders and British women. Infibulation was banned there in 1946, but the law was unpopular and barely enforced. The Egyptian government banned infibulation in state-run hospitals in 1959, but allowed partial clitoridectomy if parents requested it. (Egypt banned FGM entirely in 2007.)

In 1959 the UN asked the WHO to investigate FGM, but the latter responded that it was not a medical matter. Feminists took up the issue throughout the 1970s. The Egyptian physician and feminist Nawal El Saadawi criticized FGM in her book Women and Sex (1972); the book was banned in Egypt and El Saadawi lost her job as director general of public health. She followed up with a chapter, "The Circumcision of Girls," in The Hidden Face of Eve: Women in the Arab World (1980), which described her own clitoridectomy when she was six years old:

I did not know what they had cut off from my body, and I did not try to find out. I just wept, and called out to my mother for help. But the worst shock of all was when I looked around and found her standing by my side. Yes, it was her, I could not be mistaken, in flesh and blood, right in the midst of these strangers, talking to them and smiling at them, as though they had not participated in slaughtering her daughter just a few moments ago.

In 1975 Rose Oldfield Hayes, an American social scientist, became the first female academic to publish a detailed account of FGM, aided by her ability to discuss it directly with women in Sudan. Her article in American Ethnologist called it "female genital mutilation," rather than female circumcision, and brought it to wider academic attention.

In 1977 Edna Adan Ismail, who worked at the time for the Somalia Ministry of Health, raised the health consequences of FGM with the Somali Women's Democratic Organization. Two years later Fran Hosken, an Austria-American feminist, published The Hosken Report: Genital and Sexual Mutilation of Females (1979), the first to offer global figures. She estimated that 110,529,000 women in 20 African countries had experienced FGM. The figures were speculative but consistent with later surveys. Describing FGM as a "training ground for male violence," Hosken accused female practitioners of "participating in the destruction of their own kind." The language caused a rift between Western and African feminists; African women boycotted a session featuring Hosken during the UN's Mid-Decade Conference on Women in Copenhagen in July 1980.

In 1979 the WHO held a seminar, "Traditional Practices Affecting the Health of Women and Children," in Khartoum, Sudan, and in 1981, also in Khartoum, 150 academics and activists signed a pledge to fight FGM after a workshop held by the Babiker Badri Scientific Association for Women's Studies (BBSAWS), "Female Circumcision Mutilates and Endangers Women – Combat it!" Another BBSAWS workshop in 1984 invited the international community to write a joint statement for the United Nations. It recommended that the "goal of all African women" should be the eradication of FGM and that, to sever the link between FGM and religion, clitoridectomy should no longer be referred to as sunna.

The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, founded in 1984 in Dakar, Senegal, called for an end to the practice, as did the UN's World Conference on Human Rights in Vienna in 1993. The conference listed FGM as a form of violence against women, marking it as a human-rights violation, rather than a medical issue. Throughout the 1990s and 2000s governments in Africa and the Middle East passed legislation banning or restricting FGM. In 2003 the African Union ratified the Maputo Protocol on the rights of women, which supported the elimination of FGM. By 2015 laws restricting FGM had been passed in at least 23 of the 27 African countries in which it is concentrated, although several fell short of a ban.

United Nations

In December 1993 the United Nations General Assembly included FGM in resolution 48/104, the Declaration on the Elimination of Violence Against Women, and from 2003 sponsored International Day of Zero Tolerance to Female Genital Mutilation, held every 6 February.

UNICEF began in 2003 to promote an evidence-based social norms approach to the evaluation of intervention, using ideas from game theory about how communities reach decisions about FGM, and building on the work of Gerry Mackie on the ending of footbinding in China. In 2005 the UNICEF Innocenti Research Centre in Florence published its first report on FGM.

UNFPA and UNICEF launched a joint programme in Africa in 2007 to reduce FGM by 40 percent within the 0–15 age group and eliminate it from at least one country by 2012, goals that were not met. In 2008 several UN bodies recognized FGM as a human-rights violation, and in 2012 the General Assembly passed resolution 67/146, "Intensifying global efforts for the elimination of female genital mutilations."

Non-practising countries

Immigration spread the practice to Australia, New Zealand, Europe, North America and Scandinavia, all of which outlawed it entirely or restricted it to consenting adults. Sweden outlawed it in 1982, the first Western country to do so. Several former colonial powers, including Belgium, Britain, France and the Netherlands, introduced new laws or made clear that it was covered by existing legislation. As of 2013 legislation banning FGM had been passed in 33 countries outside Africa and the Middle East.

North America

Canada recognized FGM as a form of persecution in July 1994, when it granted refugee status to Khadra Hassan Farah, who had fled Somalia to avoid her daughter being cut. In 1997 section 268 of its Criminal Code was amended to ban FGM, except where "the person is at least eighteen years of age and there is no resulting bodily harm." As of May 2016 there had been no prosecutions.

In the United States an estimated 513,000 women and girls had experienced FGM or were at risk as of 2012. A Nigerian woman successfully contested deportation in March 1994 on the grounds that her daughters might be cut, and in 1996 Fauziya Kasinga from Togo became the first to be granted asylum to escape FGM. In 1996 the Federal Prohibition of Female Genital Mutilation Act made it illegal to perform FGM on minors for non-medical reasons, and in 2013 the Transport for Female Genital Mutilation Act prohibited transporting a minor out of the country for the purpose of FGM. In addition, 24 states have legislation banning FGM. The American Academy of Pediatrics opposes all forms of the practice. The first FGM conviction in the US was in 2006, when Khalid Adem, who had emigrated from Ethiopia, was sentenced to ten years after severing his two-year-old daughter's clitoris with a pair of scissors.

Europe

According to the European Parliament, 500,000 women in Europe had undergone FGM as of March 2009. France is known for its tough stance against FGM. Up to 30,000 women there were thought to have experienced it as of 1995. According to Colette Gallard, a family-planning counsellor, when FGM was first encountered in France, the reaction was that Westerners ought not to intervene. It took the deaths of two girls in 1982, one of them three months old, for that attitude to change. In 1991 a French court ruled that the Convention Relating to the Status of Refugees offered protection to FGM victims; the decision followed an asylum application from Aminata Diop, who fled an FGM procedure in Mali.

The practice is outlawed by a provision of France's penal code dealing with violence against children. All children under six who were born in France undergo medical examinations that include inspection of the genitals, and doctors are obliged to report FGM. The first civil suit was in 1982 and the first criminal prosecution in 1993. In 1999 a woman was given an eight-year sentence for having performed FGM on 48 girls. By 2014 over 100 parents and two practitioners had been prosecuted in over 40 criminal cases.

Around 137,000 women and girls living in England and Wales were born in countries where FGM is practised (as of 2011). Performing FGM on children or adults was outlawed under the Prohibition of Female Circumcision Act 1985. This was replaced by the Female Genital Mutilation Act 2003 and Prohibition of Female Genital Mutilation (Scotland) Act 2005, which added a prohibition on arranging FGM outside the country for British citizens or permanent residents. The United Nations Committee on the Elimination of Discrimination against Women asked the government in 2013 to "ensure the full implementation of its legislation on FGM." The first charges were brought the following year against a physician and another man, after the physician stitched an infibulated woman after opening her for childbirth. Both men were acquitted in 2015.

Tolerance versus human rights

Anthropologist Eric Silverman wrote in 2004 that FGM had "emerged as one of the central moral topics of contemporary anthropology." Anthropologists have accused FGM eradicationists of cultural colonialism. In turn, anthropologists have been criticized for their moral relativism and failure to defend the idea of universal human rights.

According to the opposition's critics, the biological reductionism of the opposition to FGM, and the failure to appreciate FGM's cultural context, serves to "other" practitioners and undermines their agency—in particular when parents are referred to as "mutilators". Africans who object to the tone of the opposition to FGM risk appearing to defend the practice. Feminist theorist Obioma Nnaemeka—herself strongly opposed to FGM ("If one is circumcised, it is one too many")—argues that renaming it female genital mutilation introduced "a subtext of barbaric African and Muslim cultures and the West's relevance (even indispensability) in purging [it]".

According to Ugandan law professor Sylvia Tamale, early Western opposition to FGM stemmed from a Judeo-Christian judgment that African sexual and family practices—including dry sex, polygyny, bride price and levirate marriage—were primitive and required correction. African feminists "do not condone the negative aspects of the practice", writes Tamale, but "take strong exception to the imperialist, racist and dehumanising infantilization of African women".

The debate has highlighted a tension between anthropology and feminism, with the former's focus on tolerance and the latter's on equal rights for all women. According to the anthropologist Christine Walley, a common trope within the anti-FGM literature has been to present African women as victims of false consciousness participating in their own oppression, a position promoted by feminists in the 1970s and 1980s, including Fran Hosken, Mary Daly and Hanny Lightfoot-Klein. It prompted the French Association of Anthropologists to issue a statement in 1981, at the height of the early debates, that "a certain feminism resuscitates (today) the moralistic arrogance of yesterday's colonialism."

Commentators highlight the appropriation of women's bodies as exhibits. Historian Chima Korieh cites the publication in 1996 of the Pulitzer-prize-winning photographs (above) of a 16-year-old Kenyan girl undergoing FGM. The photographs were published by 12 American newspapers, although the girl had not given permission for the images to be taken, much less published.

Comparison with other procedures

Nnaemeka argues that the crucial question, broader than FGM, is why the female body is subjected to so much "abuse and indignity", including in the West. Several authors have drawn a parallel between FGM and cosmetic procedures. Ronán Conroy of the Royal College of Surgeons in Ireland wrote in 2006 that cosmetic genital procedures were "driving the advance of female genital mutilation" by encouraging women to see natural variations as defects. Anthropologist Fadwa El Guindi compares FGM to breast enhancement, in which the maternal function of the breast becomes secondary to men's sexual pleasure. Benoîte Groult made a similar point in 1975, citing FGM and cosmetic surgery as sexist and patriarchal.

Carla Obermeyer maintains that FGM may be conducive to a subject's social well-being in the same way that rhinoplasty and male circumcision are. In Egypt, despite the 2007 ban, women wanting FGM for their daughters seek amalyet tajmeel (cosmetic surgery) to remove what is viewed as excess genital tissue for a more acceptable appearance.

The WHO does not cite procedures such as labiaplasty and clitoral hood reduction as examples of FGM, but its definition aims to avoid loopholes, so several elective practices fall within its categories. Some of the laws banning FGM, including in Canada and the US, focus only on minors. Several countries, including Sweden and the UK, have banned it regardless of consent, and the legislation would seem to cover cosmetic procedures. Sweden, for example, has banned "[o]perations on the external female genital organs which are designed to mutilate them or produce other permanent changes in them ... regardless of whether consent to this operation has or has not been given." Gynaecologist Birgitta Essén and anthropologist Sara Johnsdotter note that it seems the law distinguishes between Western and African genitals, and deems only African women (such as those seeking reinfibulation after childbirth) unfit to make their own decisions.

Arguing against suggested similarities between FGM and dieting or body shaping, philosopher Martha Nussbaum writes that a key difference is that FGM is mostly conducted on children using physical force. She argues that the distinction between social pressure and physical force is morally and legally salient, comparable to the distinction between seduction and rape. She argues further that the literacy of women in practising countries is generally poorer than in developed nations, and that this reduces their ability to make informed choices.

Several commentators maintain that children's rights are violated with the genital alteration of intersex children, who are born with anomalies that physicians choose to correct. Legal scholars Nancy Ehrenreich and Mark Barr write that thousands of these procedures take place every year in the United States, and say that they are medically unnecessary, more extensive than FGM, and have more serious physical and mental consequences. They attribute the silence of anti-FGM campaigners about intersex procedures to white privilege and a refusal to acknowledge that "similar unnecessary and harmful genital cutting occurs in their own backyards."