Seven Things To Know About Female Genital Surgeries In Africa

South Korea, and many countries inAfrica) during their preadolescent oradolescent years.6 Customary femalegenital surgery is far less familiar inthe United States, and also less prevalent globally, although it is practicedin many East and West African countries, among particular ethnic groupsin other regions of Africa, and in someparts of Southeast Asia (for example,Malaysia) and the Middle East.7 Nationally representative survey data onMainstream news reports on thefemale genital surgery are availabletopic have mostly followed suit, refor twenty-eight African countries.porting as establishedIn some countries,facts claims about thethe prevalence amongronically, the effect of somedisastrous health conwomen aged fifteensequences of femaleantimutilation campaigns in Africa is to to forty-nine is verygenital surgeries (inhigh (over 80 percent).bring women’s bodies and lives undercluding the attenuaThese include estition of female sexualmates from Djiboutithe hegemonic control andcapacity). Feature arti(93 percent), Egyptmanagement of local male religious orcles have deplored the(91 percent), Eritreacustom, quoting (for(89 percent), Guineapolitical leaders. We see it asexample) African an(96 percent), Mali (85preferable that any changes that maytimutilation activistspercent), Sierra Leonewho declare that febe made are led by the women of these (91 percent), Somamale genital surgery islia (98 percent), andsocieties themselves.“the most widespreadnorthern Sudan (89and deadly of all viopercent).lence victimizing women and girls obliteration of the vaginal entranceAs with customary forms of malein Africa”2 and painting the now- except for a tiny passage”) is not genital surgery, the female age forfamiliar portrait of African female factually correct, since infibulations genital modification varies considgenital surgeries as savage, horrifying, amount to approximately 10 percent erably, ranging from infancy to lateharmful, misogynist, abusive, and so- of cases across the continent, accord- adolescence. The meanings and mocially unjust—“A Rite of Torture for ing to a 2007 estimate generated by tives associated with the practice varyGirls.”3P. Stanley Yoder and Shane Khan.5 as well and are not necessarily sharedIt is noteworthy that Rosenthal That 10 percent includes surgeries by every ethnic group. Nevertheless,credited three antimutilation ad- using medical suture techniques and concerns about carrying forwardvocacy groups, including the orga- conducted under hygienic conditions one’s traditions and being includednization that publishes The Hosken in clinics or hospitals. Nevertheless, in them are commonplace. ManyReport, a document that popularized the image inscribed by Rosenthal has women who have had genital surgerthe expression “female genital muti- become the prototype of an African ies view the procedure as a cosmeticlation” and was widely distributed to female genital surgery in the minds of beautification, moral enhancement,opinion-makers and journalists in the many people.or dignifying improvement of the ap1980s and 1990s.4 The advocacy litpearance of the human body. This iserature characteristically features lists A Primer on Female Genitaltrue of both male and female genitalof short- and long-term medical com- Surgerymodifications in African cultures.plications all said to be caused by feWithin the aesthetic terms of theseustomary male genital surgery, body ideals, cosmetically unmodimale genital surgery, including bloodsuch as neonatal male circum- fied genitals in both men and womenloss, septic shock, acute infection, reduction of the sex drive, elimination cision, is a familiar practice in the are perceived and experienced as disof the capacity for orgasm, menstrual United States, and approximately 30 tasteful, unclean, excessively fleshy,problems, incontinence, sterility, percent of all males in the world have malodorous, and somewhat ugly tochild-bearing difficulties (including had their genitals surgically modi- behold and touch. The enhancementmaternal mortality), and death at an fied in some way, often (as in Turkey, of gender identity is also frequently aearly age. Over the past three decadesor so, the standard mainstream medianarrative has recapitulated and popularized many of those claims, oftenwithout independent fact checkingor a critical and balanced assessmentof the evidence.For example, looking ahead to apoint we will make later, Rosenthal’sdescription of what a typical femalegenital surgery in Africa “usually includes” (namely, “the sewing or pinning together of both sides of thevulva, by catgut or thorns, and themajora, plus the sewing or pinningtogether of both sides of the vulva,by catgut or thorns, and the obliteration of the vaginal entrance except for a tiny passage. The maleequivalent would be the removalof the penis. . . . The purpose is toinsure virginity and destroy sexualpleasure. It is a form of male control, perhaps the ultimate exceptfor murder.1ICNovember-December 2012H AS TI N GS C EN TE R RE P O RT21

significant feature of genital surgery,from the point of view of insiderswho support the practice. In the caseof male genital surgeries, the aim isto enhance male gender identity byremoving bodily signs of femininity(the foreskin is perceived as a fleshy,vagina-like female element on themale body). In the case of femalegenital surgeries, the aim is often toenhance female gender identity byremoving bodily signs of masculinity (the visible part of the clitoris isperceived as a protruding, penis-likemasculine element on the femalebody).The style and degree of surgeryalso vary. A type I female genitalsurgery, as classified by the WorldHealth Organization, is restricted toprocedures involving reduction of either the clitoral hood (the prepuce)or the external or protruding elements of clitoral tissue, or both. TypeII involves partial or complete labialreductions and partial or completereductions of the external or protruding elements of clitoral tissue. Approximately 90 percent of all femalegenital surgeries in Africa are eithertype I or type II.8 The remaining 10percent of cases, classified as type III,are those in which the operation isconcluded by shielding and narrowing the vaginal opening with stitchesor other techniques of sealing, whichforms a smooth surface of joined tissue that is opened at the time of firstsexual intercourse. This “infibulation” or “sealing” procedure occurslargely in the Northeast of Africa andamong certain Fula and other ethnicgroups across the Sahara belt. In allother regional and ethnic settings,type I and type II surgeries are mostcommon, and they are the main focusof this public policy statement.Focusing, then, primarily (although not exclusively) on the 90percent, it is our hope that some basicfact checking and a more thoroughgoing representation of the voicesof research scholars will change thecharacter of the media discussion offemale genital surgeries. We also believe that far greater attention should22 HASTI N G S C E N T E R R E P ORTbe paid to the perspectives of Africanwomen who value the practice anddescribe it accordingly (for example,as genital beautification or genitalcleansing). In what follows, we hopeto supply the public with accurate information about the practice of genital surgery in Africa and move thecoverage of the topic from an overheated, ideologically charged, andone-sided story about “mutilation,”morbidity, and patriarchal oppression to a real, evidence-based policydebate governed by the standards ofcritical reason and fact checking. Tothat end, we have all agreed to besignatories of this advisory statementdespite differences in our views of theappropriate public policy response tothe practice. The first part lists sevenfacts about female genital surgeries inAfrica that we believe to be true basedon the best research available on thetopic.Many of the facts enumeratedbelow may seem astonishing. Several counter the familiar and widelycirculated horror-inducing representations promoted by antimutilationadvocacy organizations and uncritically recapitulated by the media inthe United States, Canada, Europe,and elsewhere. The second part of thestatement traces a few policy implications and invites a more balancedpublic policy conversation.Seven Things to Know aboutFemale Genital Surgeries inAfrica1. Research by gynecologists andothers has demonstrated that a highpercentage of women who have hadgenital surgery have rich sexual lives,including desire, arousal, orgasm,and satisfaction, and their frequency of sexual activity is not reduced.9This is true of the 10 percent (typeIII) as well as the 90 percent (typesI and II). One probable explanationfor this fact is that most female erectile tissue and its structure is locatedbeneath the surface of a woman’svulva. Surgical reductions of externaltissues per se do not prevent sexualresponsiveness or orgasm. It is noteworthy that cosmetic surgeons whoperform reductions of the clitoris andthe clitoral hood in the United States,Europe, and Canada recount thatthere is usually no long-term reduction in sexual sensation, which is consistent with the findings of researchon African women.Both of these findings fit with thebroader emerging scientific understanding of sexuality as a complexinteraction of mental processes, relational dynamics, and neurophysiological and biochemical mechanisms.It should also be emphasized thatcases of sexual dysfunction and painduring sex have been reported bothby women who have undergone female genital surgery and by thosewho have not. Further research isrequired to understand the physicaland psychological impact, if any, ofvarious types of genital surgeries, theinfluence of sociocultural context,and the extent to which sexual sensation and function may be affected,particularly in cases of type III.2. The widely publicized andsensationalized reproductive healthand medical complications associated with female genital surgeries inAfrica are infrequent events and represent the exception rather than therule.10 Reviews of the medical anddemographic literature and directcomparisons of matched samples of“uncut” and “cut” (primarily type II)African women suggest that, from apublic health point of view, the vastmajority of genital surgeries in Africa are safe, even with current procedures and under current conditions.According to some medical experts,with a proper input of medical resources, the potential for harm can bereasonably managed. The exceptions,where and when they occur, are usually the result of inadequate surgicalconditions, hygiene, or malpractice,as well as relative deficiencies in thegeneral health care system in Africa.Significantly, reviews of the medicalliterature indicate that most of thewidely publicized claims about highmorbidity or mortality and negativeNovember-December 2012

reproductive health consequences of4. Customary genital surgeries are are more permissive and encouragingfemale genital surgeries do not stand not restricted to females. In almost all of sexual adventures and experimenup to critical scientific analysis. In societies where there are customary tation—but these differences do notcountries in Africa where morbidi- female genital surgeries, there are also correlate strongly with the presenceties (infertility, stillbirths, menstrual customary male genital surgeries, at or absence of female genital surgeries.problems, damage to the perineum) similar ages and for parallel reasons. In some societies where genital surare relatively high compared to North In other words, there are few societ- geries are customary for females andAmerican or European standards, ies in the world, if any, in which fe- males (for example, in Northeast Afthose morbidity levels are just as high male but not male genital surgeries rica), chastity and virginity are highlyfor “uncut” women.11 In Western are customary. As a broad generaliza- valued, and type III surgeries involvcountries, some medical experts who tion, it seems fair to say that societ- ing infibulation may be expressive oftreat affected African women suggest ies for whom genital surgeries are these values, but those chastity andthat instances of morbidity may be normal and routine are not singling virginity concerns are neither distincrelated more to miscommunication, out females as targets of punishment, tive nor characteristic of all societiesfear, distrust, delaysfor whom genital surin seeking care, andgeries are customary.avoiding medical andIndeed, female geniemale genital surgeries worldwidesurgical interventionstal surgeries are notshould be addressed in a largerthan to surgical genitalcustomary in the vastmodification per se.12majority of the world’scontext of discussions of health3. Female genitalmost sexually restricpromotion, parental and children’ssurgeries in Africative societies.are viewed by many6. Female genitalrights, religious and cultural freedom,insiders as aestheticsurgery in Africa is typgender parity, debates on permissibleenhancements of theically controlled andbody and are notmanaged by women.cosmetic alterations of the body, andjudged to be “mutiSimilarly, male genitalfemale empowerment issues.lations.”13 From thesurgery is usually conperspective of thosetrolled and managedwho value these surgeries, they are as- sexual deprivation, or humiliation. by men. Although both men andsociated with a positive aesthetic ideal The frequency with which over- women play roles in perpetuating andaimed at making the genitals more heated, rhetorically loaded, and in- supporting the genital modificationattractive—“smooth and clean.” The appropriate analogies are invoked in customs of their cultures, female gensurgeries also serve to enhance gen- the antimutilation literature (“female ital surgery should not be blamed onder identity from the point of view castration,” “sexual blinding of wom- men or on patriarchy. Demographicof many insiders. These aesthetic and en,” and so on) is both a measure of and health survey data reveal thatgender identity norms are in flux and the need for more balanced critical when compared with men, an equalare variable even among mainstream thinking and open debate about this or higher proportion of women favorpopulations in Europe and North topic and one of the reasons we are the continuation of female genitalAmerica. The globalization of images publishing this public policy advisory surgeries. A more thoughtful analysisof women’s bodies has increasingly statement.is needed: those who want to ensurepopularized the ideal of a smooth5. The empirical association be- that women have a say in the conductand clean genital look that is remi- tween patriarchy and genital surger- of their lives should support womenniscent of the aesthetic standards as- ies is not well established. The vast in their quest for choices about theirsociated with genital surgeries in East majority of the world’s societies can own bodies and traditions. Ironiand West Africa. As an index of this be described as patriarchal, and most cally, the effect of some antimutilarecent trend, although the number either do not modify the genitals of tion campaigns in Africa is to weakenof operations performed each year is either sex or modify the genitals of female power centers within societyquite small, type I and type II genital males only. There are almost no patri- and bring women’s bodies and livessurgeries (described as clitoroplexy, archal societies with customary geni- under the hegemonic control andclitoral reduction, and labiaplasty tal surgeries for females only. Across management of local male religiousby cosmetic surgeons) are gaining in human societies there is a broad range or political leaders. We see it as prefpopularity in North America and Eu- of cultural attitudes concerning fe- erable that any changes that may berope in what is now one of the fastest male sexuality—from societies that made are led by the women of thesegrowing forms of cosmetic surgery in press for temperance, restraint, and societies themselves.those regions of the world.14the control of sexuality to those thatFNovember-December 2012H AS TI N GS C EN TE R RE P O RT23

7. The findings of the WHO StudyGroup on Female Genital Mutilation and Obstetric Outcome15 is thesubject of criticism that has not beenadequately publicized. The reportedevidence does not support sensationalmedia claims about female genitalsurgery as a cause of perinatal andmaternal mortality during birth.The WHO study was published inthe prestigious medical journal Lancet in 2006 and received widespreadand rather sensationalized coverageby the media. A story in the New YorkTimes began as follows: “The firstlarge medical study of female genitalcutting has found that the procedurehas deadly consequences when thewomen give birth, raising by morethan 50 percent the likelihood thatthe woman or her baby will die.”16A careful reading of the WHOstudy reveals that the results are verycomplex. There were no statisticallysignificant differences in reproductive health between those who hada type I genital surgery and thosewho had no surgery. The perinatal death rate for the women in thesample who had a type III surgerywas, in fact, lower (193 infant deathsout of 6,595 births) than for thosewho had no surgery at all (296 infant deaths out of 7,171 births) andbecame statistically significant onlythrough nontransparent statisticaladjustment of the data. After statistical adjustments, there was no significant difference in risk of maternalmortality when comparing “uncut”women with the sample of womenwith type I and type III genital surgeries. “Infibulated” women did nothave higher maternal mortality than“uncut” women, although womenwith type II surgeries did. Maternaldeath was not a frequent event. Theabsolute raw numbers for maternaldeaths were as follows: out of 28,393deliveries, fifty-four women died before discharge: nine had no femalegenital surgeries, fifteen had type I,twenty-three had type II, and sevenhad type III. The study collected dataon women across six nations but did24 HASTI N G S C E N T E R R E P ORTnot display the within-nation resultsso that one could determine if theresults replicated well. There was nodirect control for the quality of healthcare available for “cut” versus “uncut”women. Although it is understandable that a hospital-based study couldnot offer a sample that would represent the whole population, a dispassionate assessment of the WHO studygroup findings might well concludethat the results of the study have beensensationalized and misrepresented.The reported findings suggest that female genital surgeries are less hazardous than cigarette smoking as a riskfactor for pregnancy.17It should also be pointed out thatthe WHO study was not the firstlarge medical study of female genitalcutting. A high-quality Medical Research Council study of the reproductive health of over one thousand “cut”and “uncut” women in the Gambiapublished in 2001 suggested thatmany of the reproductive morbiditiespublicized by antimutilation activistswere equally prevalent among “uncut” women.18 That study receivedno media attention.Policy Implications1. Better fact checking and betterrepresentation of the voices of scholarsand the perspectives and experiencesof African women who value femalegenital surgery are likely to changethe character of the discussion. Fornearly three decades, there has beenan uncritical relationship betweenthe media and antimutilation advocacy groups. In the face of horrifyingand sensational claims about Africanparents “mutilating” their daughtersand damaging their sexual pleasureand reproductive capacities, there hasbeen surprisingly little journalistic exploration of alternative views or consultation with experts who can assesscurrent evidence.We recommend that journalists,activists, and policy-makers cease using violent and preemptive rhetoric.We recommend a more balanceddiscussion of the topic in the pressand in public policy forums. Femalegenital surgeries worldwide shouldbe addressed in a larger context ofdiscussions of health promotion, parental and children’s rights, religiousand cultural freedom, gender parity,debates on permissible cosmetic alterations of the body, and female empowerment issues.The voices of African womenwho support female and male genitalmodification for their children andthemselves have not been adequatelyrepresented in the media or in publicpolicy forums. These parents are neither monsters nor fools: like parentseverywhere, they want to do the rightthing for their children and are concerned about their children’s health.Nor are they necessarily uneducatedor ignorant or helpless prisoners ofan insufferably dangerous traditionthat they themselves would like toescape, if only they could find a wayout. Many highly educated women inAfrica embrace the practice and do sowithout negative health consequences. For the sake of a balanced discussion, it will be necessary to create acontext where women can expresstheir support for the practices without being attacked. African womenwho live outside Africa but who grewup in regions of Africa where genitalsurgeries are routine and have a positive connotation should be includedin a more respectful and productivediscourse that creates a supportiveor protective context against stigmatization, fear, or humiliation. Somemedical practitioners have suggestedthat the horror-inducing media coverage of the topic over the past threedecades can have a psychological impact on a woman’s genital self-imageupon immigration to countries wherefemale genital surgery is condemned,thereby inducing an “acquired sexualdysfunction.”192. It should be acknowledgedthat female genital surgeries are notunique to African women. Surgical practices that reduce or alter theexternal genitalia of women includeNovember-December 2012

Further ReadingSome of the publications cited in the endnotes provide a core reading list for readers wanting more information about female genitalsurgeries. Other relevant publications are listed here.1.J. Abdulcadir et al., “Care of Women with Female GenitalMutilation/Cutting,” Swiss Medical Weekly 140 (2011):w13137.2.R. Abusharaf, “Virtuous Cuts: Female Genital Mutilationin an African Ontology,” Differences: A Journal of FeministCultural Studies 12 (2001): 112-40.3.4.5.K. Bell, “Genital Cutting and Western Discourses onSexuality,” Medical Anthropology Quarterly 19, no. 2(2005): 125-48.J. Boddy, Civilizing Women: British Crusades in ColonialSudan (Princeton, N.J.: Princeton University Press, 2007).J. Boddy, “Violence Embodied? Circumcision, GenderPolitics, and Cultural Aesthetics,” in Rethinking ViolenceAgainst Women, ed. R.E. Dobash and R.P. Dobash(Thousand Oaks, Calif.: Sage, 1996).6.J. Boddy, “Womb as Oasis: The Symbolic Context ofPharaonic Circumcision in Rural Northern Sudan,”American Ethnologist 9 (1982): 682-98.7.D.L. Coleman, “The Seattle Compromise: MulticulturalSensitivity and Americanization,” Duke Law Review 47(1998): 717-83.15. C. Kratz, “Female Circumcision in

Female Genital Surgeries in Africa By THE PuBlIC POlICy ADVISORy NETwORK ON FEMAlE GENITAl SuRGERIES IN AFRICA western media coverage of female genital modifications in Africa has been hyperbolic and one-sided, presenting them uniformly as mutilation and ignoring the cultural complexities that underlie these practices.