Female genital cutting

Female genital cutting (FGC), also known as female genital mutilation (FGM), female circumcision or female genital mutilation/cutting (FGM/C), refers to "all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons." The term is almost exclusively used to describe traditional, cultural, and religious procedures where parents must give consent, due to the minor age of the subject, rather than to procedures generally done with self-consent (such as labiaplasty and vaginoplasty). It also generally does not refer to procedures used in gender reassignment surgery, and the genital modification of intersexuals.

FGC is practiced throughout the world, with the practice concentrated most heavily in Africa. Its practice is extremely controversial. Opposition is motivated by concerns regarding the consent (or lack thereof, in most cases) of the patient, and subsequentely the safety and consequences of the procedures. In the past several decades, there have been many concentrated efforts by the World Health Organization (WHO) to end the practice of FGC. The WHO separates FGC procedures into four categories (see World Health Organization categorization below).

History of terminology
Different terms are used to describe female genital surgery and other such procedures. The procedures were commonly referred to as female circumcision, but the terms female genital mutilation (FGM) and female genital cutting (FGC) are now dominant throughout the international community. Opponents of the practice often use the term female genital mutilation, whereas groups that oppose the stigma of the word "mutilation" prefer to use the term female genital cutting. A few organizations have started using the combined term female genital mutilation/cutting (FGM/C). Some twenty-first century scholars continue to refer to the procedures as female circumcision.

Female circumcision
Several dictionaries, including medical dictionaries, define the word circumcision as applicable to procedures performed on females. Morison et al. state that female circumcision is a commonly used term for the procedures. Cook states that historically, the term female circumcision was used, but that "this procedure in whatever form it is practised is not at all analogous to male circumcision." Shell-Duncan states that the term female circumcision is a euphemism for a variety of procedures for altering the female genitalia. Toubia argues that the term female circumcision "implies a fallacious analogy to nonmutilating male circumcision".

Female genital mutilation
The term female genital mutilation gained growing support in the late 1970s. The word "mutilation" not only established clear linguistic distinction from male circumcision, but it also emphasized the gravity of the act. In 1990, this term was adopted at the third conference of the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children (IAC) in Addis Ababa. In 1991, the World Health Organization (WHO), a specialized agency of the United Nations (UN), recommended that the UN adopt this terminology; subsequently, it has been widely used in UN documents.

In this context, the term female circumcision was thus predominantly replaced by the term female genital mutilation: "The extensive literature on the subject, the support of international organizations, and the emergence of local groups working against the continuation practices appear to suggest that an international consensus has been reached. The terminology used to refer to these surgeries has changed, and the clearly disapproving and powerfully evocative expression of 'female genital mutilation' has now all but replaced the possibly inaccurate, but relatively less value laden-term of 'female circumcision'."

Female genital cutting
Because the term female genital mutilation has been criticized for increasing the stigma associated with female genital surgery, some groups have proposed an alteration, substituting the word "cutting" for "mutilation." According to a joint WHO/UNICEF/UNFPA statement, the use of the word "mutilation" reinforces the idea that this practice is a violation of the human rights of girls and women, and thereby helps promote national and international advocacy towards its abandonment. They state that, at the community level, however, the term can be problematic; and that local languages generally use the less judgmental "cutting" to describe the practice. They also feel that parents resent the suggestion that they are "mutilating" their daughters. In this spirit, in 1999, the UN Special Rapporteur on Traditional Practices called for tact and patience regarding activities in this area and drew attention to the risk of "demonizing" certain cultures, religions, and communities. As a result, they claim, the term "cutting" has increasingly come to be used to avoid alienating communities.

In 1996, the Uganda-based initiative REACH (Reproductive, Educative, And Community Health) began using the term "FGC", observing that "FGM" may "imply excessive judgment by outsiders as well as insensitivity toward individuals who have undergone some form of genital excision." The UN uses "FGM" in official documents, while some of its agencies, such as the UN Population Fund, use both the terms "FGM" and "FGC".

FGC Procedures
FGC consists of several distinct procedures. Their severity is often viewed as dependent on how much genital tissue is cut away.

World Health Organization categorization
The WHO uses the term Female Genital Mutilation, and classifies FGM into four major types (see Diagram 1), although there is some debate as to whether all common forms of FGC fit into these four categories, as well as issues with the reliability of reported data.



Type I
The WHO defines Type I FGM as the partial or total removal of the clitoris (clitoridectomy),and/or the prepuce removal clitoral hood, see Diagram 1B. When it is important to distinguish between the major variations of Type I mutilation, the following subdivisions are proposed: Type Ia, removal of the clitoral hood or prepuce only; Type Ib, removal of the clitoris with the prepuce. In the context of women who seek out labiaplasty, Stern opposes removal of the clitoral hood and points to potential scarring and nerve damage.

Type II
The WHO's definition of Type II FGM is "partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision). When it is important to distinguish between the major variations that have been documented, the following subdivisions are proposed: Type IIa, removal of the labia minora only; Type IIb, partial or total removal of the clitoris and the labia minora; Type IIc, partial or total removal of the clitoris, the labia minora and the labia majora. Note also that, in French, the term ‘excision’ is often used as a general term covering all types of female genital mutilation.

Type III: Infibulation with excision
The WHO defines Type III FGC as narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation)." It is the most extensive form of FGM, and accounts for about 10% of all FGM procedures described from Africa.  Infibulation is also known as "pharaonic circumcision."

In a study of infibulation in the Horn of Africa, Pieters observed that the procedure involves extensive tissue removal of the external genitalia, including all of the labia minora and the inside of the labia majora. The labia majora are then held together using thorns or stitching. In some cases the girl's legs have been tied together for two to six weeks, to prevent her from moving and to allow the healing of the two sides of the vulva. Nothing remains but the walls of flesh from the pubis down to the anus, with the exception of an opening at the inferior portion of the vulva to allow urine and menstrual blood to pass through, see Diagram 1D. Generally, a practitioner deemed to have the necessary skill carries out this procedure, and a local anesthetic is used. However, when carried out "in the bush," infibulation is often performed by an elderly matron or midwife of the village, with no anesthesia used.

A reverse infibulation can be performed to allow for sexual intercourse or when undergoing labor, or by female relatives, whose responsibility it is to inspect the wound every few weeks and open it some more if necessary. During childbirth, the enlargement is too small to allow vaginal delivery, and so the infibulation is opened completely and may be restored after delivery. Again, the legs are sometimes tied together to allow the wound to heal. When childbirth takes place in a hospital, the surgeons may preserve the infibulation by enlarging the vagina with deep episiotomies. Afterwards, the patient may insist that her vulva be closed again.

This practice increases the occurrence of medical complications due to a lack of modern medicine and surgical practices.

A five-year study of 300 women and 100 men in Sudan found that "sexual desire, pleasure, and orgasm are experienced by the majority of women who have been subjected to this extreme sexual mutilation, in spite of their being culturally bound to hide these experiences."

Most advocates of the practice continue to perform the procedure in adherence to standards of beauty that are very different from those in the west. Many infibulated women will contend that the pleasure their partners receive due to this procedure is a definitive part of a successful marriage and enjoyable sex life.

Type IV: Other types
There are other forms of FGM, collectively referred to as Type IV, that may not involve tissue removal. The WHO defines Type IV FGC as "all other harmful procedures to the female genitalia for non-medical purposes, for example, pricking, piercing, incising, scraping and cauterization." This includes a diverse range of practices, such as pricking the clitoris with needles, burning or scarring the genitals as well as ripping or tearing of the vagina. Type IV is found primarily among isolated ethnic groups as well as in combination with other types.

Prevalence
Amnesty International estimates that over 130 million women worldwide have been affected by some form of FGC, with over 2 million procedures being performed every year. FGC is mainly practiced in African countries. It is common in a band that stretches from Senegal in West Africa to Ethiopia on the East coast, as well as from Egypt in the north to Tanzania in the south; see Map. It is also practiced by some groups in the Arabian peninsula. The country where FGC is most prevalent is Egypt, followed by Sudan, Ethiopia, and Mali. Egypt recently passed a law banning FGC.

Whilst FGC is widely practiced out in the open by Africans of varied faiths, it is practiced in secrecy in some parts of the Middle East. In the Arabian peninsula, Types I and II FGC is usually performed, often referred to as Sunna circumcision especially among Arabs (ethnic groups of African descent are more likely to prefer infibulation). The practice occurs particularly in northern Saudi Arabia, southern Jordan, and Iraq. In the Iraqi village of Hasira, a recent study found that 60 percent of the women and girls reported having undergone FGC. Prior to the study, there had been no solid proof of the prevalence of the practice. There is also circumstantial evidence to suggest that FGC is practiced in Syria, western Iran, and southern Turkey. In Oman, a few communities still practice FGC; however, experts believe that the number of such cases is small and declining annually. In the United Arab Emirates and Saudi Arabia, it is practiced mainly among foreign workers from East Africa and the Nile Valley.

The practice can also be found among a few ethnic groups in South America and very rarely in India (Dawoodi Bohra community ). In Indonesia, the practice is not uncommon among the country's rural women; almost all are Type I or Type IV, the latter usually involving the pricking of blood release. Sometimes the procedures are merely symbolic, and no actual cutting is done.

Due to immigration, the practice has also spread to Europe, Australia and the United States. Some tradition-minded families have their daughters undergo FGC whilst on vacation in their home countries. As Western governments become more aware of FGC, legislation has come into effect in many countries to make the practice of FGC a criminal offense. In 2006, Khalid Adem became the first man in the United States to be prosecuted for mutilating his daughter.

Cultural and religious aspects
The traditional cultural practice of FGC predates both Islam and Christianity. A Greek papyrus from 163 B.C. mentions girls in Egypt undergoing circumcision and it is widely accepted to have originated in Egypt and the Nile valley at the time of the Pharaohs. Evidence from mummies have shown both Type I and Type III FGC present. While the spread of the practice of FGC is unknown, the procedure is now practiced among Muslims, Christians, and Animists.

Although FGC is practiced within particular religious sub-cultures, FGC transcends religion as it is primarily a cultural practice. UNICEF stated that when "looking at religion independently, it is not possible to establish a general association with FGM/C status." The arguments used to justify FGC vary; they range from health-related to social benefits:


 * maintenance of cleanliness
 * maintenance of good health
 * preservation of virginity
 * enhancement of fertility
 * prevention of promiscuity
 * increase of matrimonial opportunities
 * pursuance of aesthetics
 * improvement of male sexual performance and pleasure
 * promotion of social and political cohesion

Medical justifications offered by cultural tradition are regarded by scientists and doctors as unsubstantiated. Some African societies consider FGC part of maintaining cleanliness as it removes secreting parts of the genitalia. Vaginal secretions, in reality, play a critical part in maintaining female health. The Mossi of Burkina Faso and the Ibos of Nigeria believe that babies die if they touch the clitoris during birth. In some areas of Africa, there exists the belief that a newborn child has elements of both sexes. In the male body the foreskin of the penis is considered to be the female element. In the female body the clitoris is considered to be the male element. Hence when the adolescent is reaching puberty, these elements are removed to make the indication of sex clearer.

In years past, doctors advocating or performing these procedures sometimes claimed that girls of all ages would otherwise engage in excessive masturbation and be "polluted" by the activity, which was referred to as "self-abuse".

C.F. McDonald wrote in a 1958 paper titled "Circumcision of the Female" "If the male needs circumcision for cleanliness and hygiene, why not the female? I have operated on perhaps 40 patients who needed this attention." The author describes symptoms as "irritation, scratching, irritability, masturbation, frequency and urgency," and in adults, smegmaliths causing "dyspareunia and frigidity." The author then reported that a two-year old was no longer masturbating so frequently after the procedure. Of adult women, the author stated that "for the first time in their lives, sex ambition became normally satisfied." Justification of the procedure on hygienic grounds, or to reduce masturbation, has since declined. The view that masturbation is a cause of mental and physical illness has dissipated since the mid-20th century.

Clitorecdomy in its less invasive form, removal of the prepuce alone, also called a hoodectomy. It is an elective surgery undertaken by mature consenting adults. Some doctors and other advocators believe that hoodectomy can help to increase and improve sexual sensitivity and sexual pleasure in cases where the hood of the clitoris is too tight.

There are websites promoting the practice like Circlist, BMEzine (Body Modification E-Zine), and the Clitoral Hood Removal Information Page contain testimonials and citations of medical studies, which support this claim (for example a study done in 1959 Rathmann et al claim that 87.5% of women saw an improvement in sexual pleasure following a hoodectomy, with 75% in a study by Knowles et al).

Social justifications similarly lack scientific evidence. FGC advocates have claimed the practice cures females of a myriad of psychological diseases including depression, hysteria, insanity and kleptomania. FGC is often used as a means of control over female virtue. FGC is often used as a means of preservation and proof of virginity, and is regarded in many societies as a prerequisite for honorable marriage. Type III FGC is often used in these societies, and the husband will sometimes cut his bride's scar tissue open after marriage to allow for sexual intercourse. Heavy stigma lies on men who marry an uncircumcised woman. Women who have had genital surgeries are often considered to have higher status than those who have not and are entitled to positions of religious, political and cultural power. Removal of the clitoris is often cited as a means of discouraging promiscuity, as it eliminates the motivating factor of sexual pleasure. Feminists and human rights activists disapprove of this practice because it presupposes that women lack the self control or the right to decide when and with whom they engage in sexual activity.

Aesthetic reasons are also cited. Some societies believe that FGC enhances beauty. This stems from their belief that male foreskin is removed for aesthetic reasons, and that the clitoris thus should be removed for the same reason since it is the counterpart to the penis. FGC is believed to prolong sexual pleasure of men, because it is believed that the clitoris increases sexual stimulation.

There are no scientific or medical studies that support any of these viewpoints. While there is a correlation between FGC prevalence and religions like Islam and Christianity, prevalence rates vary by culture. These variances preclude an unequivocal link between religion and FGC. However there is debate as to whether or not FGC constitutes a religious practice in particular religious sub-cultures.

Islam
Female genital cutting predates Islam. In Saudi Arabia, in the area known as the Hijaz, where Islam originated, FGC was already being practiced during the lifetime of Muhammad. To call a man a "circumciser of women" was an insult among the pagan Arabs at the time. Female genital cutting is not commanded by the Qur'an and is not practiced by the majority of Muslims. In Egypt, mufti Sheikh Ali Gomaa stated: "The traditional form of excision is a practice totally banned by Islam because of the compelling evidence of the extensive damage it causes to women's bodies and minds."

Sunni View
There are differences of opinion among Sunni scholars in regards to female genital cutting. These differences of opinion range from forbidden to obligatory. The debate focuses around a hadith from the Sunni collections. One narration states that "a woman used to perform circumcision in Medina. Muhammad said to her, 'Do not cut severely as that is better for a woman and more desirable for a husband.'" Abu Dawood, who relates the narration in his collection, states the hadith is poor in authenticity. Ibn Hajar al-Asqalani describes this hadith as poor in authenticity, and quotes Imam Ahmad Bayhaqi’s point of view that it is "poor, with a broken chain of transmission" Zein al-Din al-Iraqi points out in his commentary on Al-Ghazali’s Ihya ulum al-din (I:148) that the mentioned hadith has a weak chain of transmission." Yusuf ibn Abd-al-Barr comments: "Those who consider (female) circumcision a sunna, use as evidence this hadith of Abu al-Malih, which is based solely on the evidence of Hajjaj ibn Artaa, who cannot be admitted as an authority when he is the sole transmitter. The consensus of Muslim scholars shows that circumcision is for men".

Shams Ed-Din Al-Haq Al-'Azim Abadi claims that, "[t]he Hadith of female circumcision has been reported through so many ways all of which are weak, blemished and defective, and thus it is unacceptable to prove a legal ruling through such ways." While some scholars reject ahadith that refer to FGC on grounds of inauthenticity, other scholars argue that authenticity alone does not confer legitimacy. One of the sayings used to support FGC practices is the hadith (349) in Sahih Muslim: Aishah narrated an authentic Hadith that the Prophet said:"When a man sits between the four parts (arms and legs of his wife) and the two circumcised parts meet, then ghusl is obligatory." Dr. Muhammad Salim al-Awwa, Secretary General of the World Union of the Muslim Ulemas states that while the hadith is authentic, it is not evidence of legitimacy. He states that the Arabic for "the two circumcision organs" is a single word used to connote two forms; however the plural term for one of the forms is used to denote not two of the same form, but two different forms characterized as a singular of the more prominent form. He goes on to state that, while the female form is used to denote both male and female genitalia, it is identified with the prominent aspect of the two forms, which, in this case, is the male circumcised organ. He further states that the connotation of circumcision is not transitive. Dr. al-Awwa concludes that the hadith is specious because "such an argument can be refuted by the fact that in Arabic language, two things or persons may be given one quality or name that belongs only to one of them for an effective cause." [e.g. the usage in "Qur'an in Surah Al-Furqan(25):53" "bahrayn" is the dual form of "bahr" (sea) meaning "sea (salty and bitter) and river (sweet and thirst-allaying) (not "two seas"); sometimes the word with the female gender is chosen to make the dual form, such as in the expression "the two Marwas", referring to the two hills of As-Safa and Al-Marwa (not "two hills, each called Al-Marwa") in Mecca]

In March 2005, Dr Ahmed Talib, Dean of the Faculty of Sharia at the Al-Azhar University, stated: "All practices of female circumcision and mutilation are crimes and have no relationship with Islam. Whether it involves the removal of the skin or the cutting of the flesh of the female genital organs... it is not an obligation in Islam." Both Christian and Muslim leaders have publicly denounced the practice of FGC since 1998. A recent conference at the Al-Azhar University in Cairo (December, 2006) brought prominent Muslim clergy to denounce the practice as not being necessary under the umbrella of Islam. Although there was some reluctance amongst some of the clergy, who preferred to hand the issue to doctors, making the FGC a medical decision, rather than a religious one, the Grand Mufti Ali Jumaa of Egypt, signed a resolution denouncing the practice.

One of the four Sunni schools of religious law, the Shafi'i school, rules that clitoridectomy is mandatory. Sheikh Faraz Rabbani states, "That which is wajib [obligatory] in the Shafi`i texts is merely slight 'trimming' of the tip of the clitoral hood - prepuce." Contrary to the WHO definition, he states that this practice is not "FGM, nor harmful to the woman or her ability to derive sexual pleasure." He states that "excision, FGM, or other harmful practices" are not permitted. In 1994, Egyptian Mufti Sheikh Jad Al-Hâqq 'Ali Jad Al-Hâqq issued a fatwa stating, "Circumcision is mandatory for men and for women. If the people of any village decide to abandon it, the village imam must fight against them as if they had abandoned the call to prayer." The Al-Azhar University in Cairo has issued several fatwas endorsing FGC, in 1949, 1951 and 1981.

Shia View
Foster states that female circumcision is rumoured to be common amongst Shi'ite communities ruled by Hezbollah in Lebanon. The procedures are outlawed by all leading Shi'ite Marjas that interpret Sharia traditions and are considered customs left over from pre-Islamic times.

Judaism
The Oxford Dictionary of the Jewish Religion states that female circumcision was never allowed in Judaism. Toubia (1995) states that female circumcision is not even mentioned in any religious text. FGC is practiced by the minority Ethiopian Jewish community (Beta Israel), formerly known as Falasha, most of whom now live in Israel. The operation may only be performed by a Jewish female. Those Ethiopian Jews who have emigrated to Israel no longer practice FGC. In general, traditional Judaism maintains that the body of a person belongs not to the person but to God. Any permanent modification of the body which does not serve the purpose of correcting a deformity is considered to be a defacement of God's property; thus, tattoos and body modifications are forbidden, with the exception of male circumcision, which is mandated.

Christianity
FGC has never been part of Christianity as a faith system. There are no scriptural or doctrinal documents existing within the larger Christian tradition that even address the issue. The only contemporary examples of Christians practicing FGC are in Africa. As FGC rituals predated the missionaries work in North Africa, many African tribes continue the practice as a matter of cultural tradition, unrelated to religious belief.

FGC advocation by Christians has been rare and isolated to extremist groups. In the United States, as recently as 1938, FGC was advocated by Reverend Oscar Lowry as a method of preventing masturbation: "While incest and illicit commerce of the sexes is abominable, there is another even more so—if that be possible—that is, the heinous sin of self-pollution or masturbation... In some cases where there may be impingement of the clitoris, a slight operation may be necessary to relieve the tension and irritation..."

Medical consequences
Among practicing cultures, FGC is most commonly performed between the ages of four and eight, but can take place at any age from infancy to adolescence. Prohibition has led to FGC going underground, at times with people who have had no medical training performing the cutting without anesthetic, sterilization, or the use of proper medical instruments. The procedure, when performed without any anesthetic, can lead to death through shock from immense pain or excessive bleeding. The failure to use sterile medical instruments may lead to infections. Other serious long term health effects are also common. These include urinary and reproductive tract infections, caused by obstructed flow of urine and menstrual blood, various forms of scarring and infertility. The first time having sexual intercourse will often be extremely painful, and infibulated women will need the labia majora to be opened, to allow their husband access to the vagina. This second cut, sometimes performed by the husband with a knife, can cause other complications to arise.

A June 2006 study by the WHO has cast doubt on the safety of genital cutting of any kind. This study was conducted on a cohort of 28,393 women attending delivery wards at 28 obstetric centers in areas of Burkina Faso, Ghana, Nigeria, Kenya, Senegal and The Sudan. A high proportion of these mothers had undergone FGC. According to the WHO criteria, all types of FGC were found to pose an increased risk of death to the baby (15% for Type I, 32% for Type II, and 55% for Type III). Mothers with FGC Type III were also found to be 30% more at risk for cesarean sections and had a 70% increase in postpartum hemorrhage compared to women without FGC. Estimating from these results, and doing a rough population estimate of mothers in Africa with FGC, an additional 10 to 20 per thousand babies in Africa die during delivery as a result of the mothers having undergone genital cutting.

In cases of repairing the damage resulting from FGC, called de-infibulation when reversing Type III FGC, this is usually carried out by a gynecologist. See also Pierre Foldes, French surgeon, who developed modern surgical corrective techniques.

A 12 year-old Egyptian girl, Badour Shaker, died in June, 2007 during or soon after a circumcision, prompting the Egyptian Health Ministry to ban the practice. She died from an overdose of anesthesia. The girl's mother, Zeniab Abdel Ghani, paid $9.00 [or 5 Pounds Sterling] to a female doctor, in an illegal clinic in the southern town of Maghagh, for the operation. The mother stated that the doctor tried to give her $3,000 to withdraw a lawsuit, but she refused.

Sexual consequences
The effect of FGC on a woman's sexual experience varies depending on many factors. FGC does not eliminate sexual pleasure for all women who undergo the procedure. Although sexual excitement and arousal for a woman during intercourse involves a complex series of nerve endings being activated and stimulated in and around her vagina, vulva (labia minora and majora), cervix, uterus and clitoris, psychological response and mind-set are also important.

Lightfoot-Klein (1989) studied circumcised and infibulated females in Sudan, stating, "Contrary to expectations, nearly 90% of all women interviewed said that they experienced orgasm (climax) or had at various periods of their marriage experienced it. Frequency ranged from always to rarely." Lightfoot-Klein stated that the quality of orgasm varied from intense and prolonged, to weak or difficult to achieve.

A study in 2007 found that in some infibulated women, some erectile tissue fundamental to producing pleasure had not been completely excised. Defibulation of subjects revealed that a part of or the whole of the clitoris was underneath the scar of infibulation. The study found that sexual pleasure and orgasm are still possible after infibulation, and that they rely heavily on cultural influences &mdash; when mutilation is lived as a positive experience, orgasm is more likely. When FGC is experienced as traumatic, its frequency drops. The study suggested that FGC women who did not suffer from long-term health consequences and are in a good and fulfilling relationship may enjoy sex, and women who suffered from sexual dysfunction as a result of FGC have a right to sex therapy.

A study by Anthropologist Rogaia M. Abusharaf, found that "circumcision is seen as 'the machinery which liberates the female body from its masculine properties' and for the women she interviewed, it is a source of empowerment and strength".

Attempts to end the practice of FGC
Despite laws forbidding the practice, FGC remains an enduring tradition in many societies and cultural groups. Political leaders have found FGC difficult to eliminate on the local level because of its cultural and sometimes political importance. For instance, in Kenya missionaries present in the 1920s and 1930s forbid their Christianised adherents to practice clitoridectomy. Female circumcision became instrumental in an ethnic independence movement among the Kikuyu, the most populous ethnic group of Kenya, inciting people to react against cultural imperialistic attacks from Europeans. Prohibition by the British of the procedure among tribes in Kenya significantly strengthened the tribes' resistance to British colonial rule in the 1950s and increased support for the Mau Mau guerrilla movement.

Because the practice holds much cultural and marital significance, FGC opponents recognize that in order to end the practice it is necessary to work closely with local communities. In order to leave no individuals handicapped, as what happened with the rapid abandonment of foot binding among the Chinese early in the 20th century, members of a marriage network must all give up the practice simultaneously.

Despite the close tie between FGC and cultural and, sometimes, religious tradition, there are cases where attempts at ending FGC have been successful. One example is in Senegal, where initiative was taken by native women working at the local level in connection with the Tostan Project. Since 1997, 1,271 villages (600,000 people), some 12% of the practicing population in Senegal, have voluntarily given up FGC and are also working to end early and forced marriage. This has come about through the voluntary efforts of locals carrying the message out to other villages within their marriage networks in a self-replicating process. By 2003, 563 villages had participated in public declarations, and the number continues to rise. By then, at least 23 villages in Burkina Faso had also held such community wide ceremonies, marking "the first public declaration to end FGC outside of Senegal and showing the replicability of the Tostan program for large-scale abandonment of this practice". Molly Melching of TOSTAN believes that in Senegal the practice of female genital mutilation could be ended within 2–5 years. She credits education, instead of cultural imperialism, for the rapid and significant changes which have occurred in Senegal.

Some countries which have prohibited FGC still experience the practice in secrecy. In many cases, the enforcement of this prohibition is a low priority for governments. Other countries have tried to educate practitioners in order to make it easier and safer, instead of outlawing the practice entirely. However, with pressure from the WHO and other groups, laws are being passed in regards to FGC. On June 28, 2007 Egypt banned female genital cutting after the death of 12-year old Badour Shaker during a genital circumcision. The Guardian of Britain reported that her death "sparked widespread condemnation" of the practice. However, Britain has had its own problem confronting cases of FGC, as immigrants from Africa have been known to send their daughters to their home nations to undergo the procedure before returning to Britain.

The United Nations Population Fund (UNFPA) has declared February 6 as the International Day Against Female Genital Mutilation. The UNFPA has stated that ''[the] practice violates the basic rights of women and girls, [...]" and "[...] female genital mutilation or cutting is not required by any religion."

Female Genital Mutilation can now be reversed thanks to a surgical technique giving back a sense of pleasure and dignity to the patients. Clitoraid, a non profit international organization, is in the process of building a hospital in Burkina Faso, West Africa, where FGM victims will be able to have their genitalia restored, free of charge thanks to the voluntary participation of surgeons such as Dr. Marci Bowers who currently operates FGM victims in the USA.

Laws and prevalence
The countries where FGC is commonly practiced were identified by the US State Department. Other information in this section is from Skaine (2005), Appendix I.


 * Burkina Faso (71.6% prevalence, Type II): A law prohibiting FGC was enacted in 1996 and went into effect in February 1997. Even before this law, however, a presidential decree had set up the National Committee against excision and imposed fines on people guilty of excising girls and women. The new law includes stricter punishment. Several women excising girls have been handed prison sentences.


 * Central African Republic (43.4% prevalence, Type I and II) : In 1996, the President issued an Ordinance prohibiting FGC throughout the country. It has the force of national law. Any violation of the Ordinance is punishable by imprisonment of from one month and one day to two years and a fine of 5,100 to 100,000 francs (approximately US$8-160). No arrests are known to have been made under the law.


 * Côte d'Ivoire ( 44.5% prevalence, Type II): A December 18, 1998 law provides that harm to the integrity of the genital organ of a woman by complete or partial removal, excision, desensitization or by any other procedure will, if harmful to a women's health, be punishable by imprisonment of one to five years and a fine of 360,000 to two million CFA Francs (approximately US$576-3,200). The penalty is five to twenty years incarceration if a death occurs during the procedure and up to five years' prohibition of medical practice, if this procedure is carried out by a doctor.


 * Djibouti (90-98% prevalence, Type II): FGC was outlawed in the country's revised Penal Code that went into effect in April 1995. Article 333 of the Penal Code provides that persons found guilty of this practice will face a five year prison term and a fine of one million Djibouti francs (approximately US$5,600).


 * Egypt (78-97% prevalence, Type I, II and III): Egypt's Ministry of Health and Population has banned all forms of female genital cutting since 2007. The ministry's ban order declared it is 'prohibited for any doctors, nurses, or any other person to carry out any cut of, flattening or modification of any natural part of the female reproductive system'. Islamic authorities in the nation also stressed that Islam opposes female circumcision. The Grand Mufti of Egypt, Ali Gomaa, said that it is "Prohibited, prohibited, prohibited." The June 2007 Ministry ban eliminated a loophole that allowed girls to undergo the procedure for health reasons. There had previously been provisions under the Penal Code involving "wounding" and "intentional infliction of harm leading to death," as well as a ministerial decree prohibiting FGC. In December 1997, the Court of Cassation (Egypt's highest appeals court) upheld a government banning of the practice providing that those who did not comply would be subjected to criminal and administrative punishments. This law had proved ineffective and in a survey in 2000, a study found that 97% of the country's population still practiced FGC. In light of the widespread practice of FGC, even after the ban in 1997, some Egyptian villages decided to voluntarily give up the practice, as was the case with Abou Shawareb, which vowed in July of 2005 to end the practice. However, it remains a culturally accepted practice, and a 2005 study found that over 95% of Egyptian women have undergone some form of FGC.

Many other Islamic Leaders in Egypt believe that Ali Gomaa had to say such fatwa due to some political reasons. The media trend in Egypt during the last 5 years is being affected by the governmental campaigns opposing FGC.


 * Eritrea (90-95% prevalence, Type I, II and III): Eritrea has outlawed all forms of female genital cutting since 2007. There have been no arrests made yet under the new law.


 * Ghana (9-15% prevalence, Type I,II and III): In 1989, the head of the government of Ghana, President Rawlings, issued a formal declaration against FGC. Article 39 of Ghana's Constitution also provides in part that traditional practices that are injurious to a person's health and well being are abolished.


 * Guinea (98.6% prevalence, Type I, II and III): FGC is illegal in Guinea under Article 265 of the Penal Code. The punishment is hard labor for life and if death results within 40 days after the crime, the perpetrator will be sentenced to death. No cases regarding the practice under the law have ever been brought to trial. Article 6 of the Guinean Constitution, which outlaws cruel and inhumane treatment, could be interpreted to include these practices, should a case be brought to the Supreme Court. A member of the Guinean Supreme Court is working with a local NGO on inserting a clause into the Guinean Constitution specifically prohibiting these practices.


 * Indonesia (No national prevalence figures avail., Type I and IV): Officials are preparing to release a decree banning doctors and paramedics from performing FGC. Azrul Azwar, The director general of community health, stated that, "All government health facilities will also be instructed to spread information about the decision as well as the redundancy of female circumcision."


 * Nigeria (25.1% prevalence, Type I, II and III): There is no federal law banning the practice of FGC in Nigeria. Opponents of these practices rely on Section 34(1)(a) of the 1999 Constitution of the Federal Republic of Nigeria that states "no person shall be subjected to torture or inhuman or degrading treatment" as the basis for banning the practice nationwide. A member of the House of Representatives has drafted a bill, not yet in committee, to outlaw this practice.


 * Senegal (5-20% prevalence, Type II and III): A law that was passed in January 1999 makes FGC illegal in Senegal. President Diouf had appealed for an end to this practice and for legislation outlawing it. The law modifies the Penal Code to make this practice a criminal act, punishable by a sentence of one to five years in prison. A spokesperson for the human rights group RADDHO (The African Assembly for the Defense of Human Rights) noted in the local press that "Adopting the law is not the end, as it will still need to be effectively enforced for women to benefit from it.


 * Sudan (91% prevalence, Type I,II and III): Currently there is no law forbidding FGC, although Sudan was the first country to outlaw it in 1946, under the British. Type III was prohibited under the 1925 Penal Code, with less severe forms allowed. Outreach groups have been trying to eradicate the practice for 50 years, working with NGO's, religious groups, the government, the media and medical practitioners. Arrests have been made but no further action seems to have taken place.


 * Tanzania (17.6% prevalence, Type II and III): Section 169A of the Sexual Offences Special Provisions Act of 1998 prohibits FGC. Punishment is imprisonment of from five to fifteen years or a fine not exceeding 300,000 shillings (approximately US$380) or both. There have been some arrests under this legislation, but no reports of prosecutions yet.


 * Togo (12% prevalence, Type II): On October 30, 1998, the National Assembly unanimously voted to outlaw the practice of FGC. Penalties under the law can include a prison term of two months to ten years and a fine of 100,000 francs to one million francs (approximately US$160 to 1,600). A person who had knowledge that the procedure was going to take place and failed to inform public authorities can be punished with one month to one year imprisonment or a fine of from 20,000 to 500,000 francs (approximately US$32 to 800).


 * Uganda (<5% prevalence, Type I and II): There is no law against the practice of FGC in Uganda. In 1996, however, a court intervened to prevent the performance of this procedure under Section 8 of the Children Statute, enacted that year, that makes it unlawful to subject a child to social or customary practices that are harmful to the child's health.

Print

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 * Dewhurst, C.J., & Michelson, A. (1964). Infibulation complicating pregnancy. British Medical Journal, 2(5422), 1442..
 * Dirie, Waris (2001). Desert Flower. Autobiography of a Somali woman's journey from nomadic tribal life to a career as a fashion model in London and to the post of special ambassador at the United Nations. Dirie recounts her personal experience with female genital mutilation that began with circumcision at age five.
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