A Policy Polemic On Female Genital Mutilation (For Northwestern University, Chicago)

I was pleased in October 2014 to write a Polemic about female genital mutilation (FGM) for the Buehler Center for Health Policy and Economics, Northwestern University, Chicago, with which I have connections as an Adjunct Professor.
The format of the piece was questions / statements and responses.  No doubt over time, as we unpick the issues further, the precise interrogation of FGM will change, but I hope nonetheless this Polemic will remain of interest. Here it is….

Time-honoured divides are sometimes so embedded that reconciliation between different perspectives looks to be impossible.

Female genital mutilation (FGM) provides one example of this divide, both because of the nature of the practice itself – anything which concerns sex or gendered beliefs can become a minefield – and because of the diametrically opposing perspectives held by its traditional proponents and those who in modern times have sought to eradicate it.

What is FGM?
In physical terms FGM comprises cutting, excision or other intentional damage to the (mostly external) female sexual organs.[1]  The labia majora and/or minora may be reduced or removed, the visible parts of the clitoris[2] may be cut or excised, the vagina may be partially or almost entirely closed (infibulated), or other harm may be inflicted. The instruments to inflict this injury can be anything from a finger nail or shell to a razor blade or scissors.  Infibulation can be achieved using thread, thorns or anything else that enables sewing up; all of which are likely unsterile, and often extremely unhygienic, leading to a very high risk of infection and sometimes even death.

But most immediately, FGM is often performed on young girls, even babies, without any form of anaesthesia.  Of course there are many variations on how and when FGM is performed, but stereotypically the child may be told she will attend a party to celebrate her coming of age (at around age 7 to 10); but when she arrives she is forcefully held down by women – or occasionally men – who assist the main operator, sometimes muting her cries with a cloth thrust into her mouth, and sometimes breaking her bones by the violence of the constraint.

It is thought that around 200 million women and girls alive today have undergone FGM; and another 30 million will join them annually for decades to come: programmes to eradicate FGM are having some success, but the relevant population – girls and young women – is currently growing at a faster rate than the impact of the various programmes.

But isn’t FGM normally just a nick, like male circumcision?
Aren’t female and male circumcision both mostly just a harmless way of expressing membership of a group?  Parents wouldn’t permit this ‘genital cutting’ if it was as bad as you suggest.

No, neither female nor male ‘cutting’ / genital mutilation (F/MGM) is harmless.  Both carry risks of infection, shock and even death, especially in the hands of inexpert operators who cause very serious damage.[3]  For women the longer term danger is that she will have ongoing problems with her monthly periods, and more difficulty giving birth, perhaps causing obstetric fistula which is a devastating condition.[4]  For males, increasingly the rationale for clinical circumcision is the prevention of HIV, but the evidence to justify this remains selective,[5] given that considerable numbers of young men in Africa die as a result of botched tribal circumcisions in their teen years.[6]

The debate about whether female and male ‘circumcision’ can be seen as parallel issues will mostly likely roll on for decades yet.  Perhaps there can be agreement that MGM in normal circumstances affects the health and well being ‘only’ of the male concerned, whilst FGM often affects not only the girl / woman concerned, but also children to whom she gives birth.  And, as many ‘intactivists’[7] will insist loudly, FGM is prohibited by many nations, whilst MGM is not. But that is not all we need to know about genital cutting….

FGM does harm to as yet unborn children, and the harm continues as they grow up
One of the additional tragedies of FGM is that it causes harm not ‘only’ to the girl or woman who undergoes it, but also quite frequently to her children, who are at greater risk of danger when they are born; and the risk remains higher throughout infancy and childhood that these children will suffer as a result of the continuing FGM-induced ill-health, or perhaps even death, of their mother.[8]

This harm arises in several other ways, alongside the hazards of giving birth after FGM.  There seems at present to be little consideration of the reduced capacity to conduct everyday business of any woman who has infections, very painful periods, probably anaemia, perhaps permanently mis-shapen or broken bones, etc.  But the impacts both on family life and on the local economy may be severe.

There is also considerable evidence that such practices may engender serious, perhaps life-long, psychological damage.[9]  In communities where FGM and MGM are widespread, if must surely be that the behaviour of the whole group, as well as the individuals personally concerned, is affected.[10]

Extraordinarily, however, the impact on communities of genital mutilation trauma across groups of individuals is barely ever acknowledged, even as a possibility.  In traditional settings this may be because notions such as ‘psychological damage’ are not part of that community’s collective understanding; and in some western societies, whilst, psychology is a given the norm has been that men are circumcised, in which case no-one is likely to recognise the potential for psychological pain.

And in both cases, men and women, who would want to believe that their parent/s permitted the imposition of a hurtful and useless procedure on their own children?

So why is FGM done?
Don’t the women who impose FGM on their daughters know, as previous victims of the act themselves, that it is a nightmarish experience which should never be perpetrated on anyone, let alone on a child who was expecting a treat?

Answers to this question are as variable as the practice itself, demonstrating the massive divide between traditional understandings of FGM and those of modern commentators, whether such commentators reside in traditionally practising countries or in western ones.

For traditionalists FGM is a non-negotiable requirement, demanded by the spirits of the ancestors whose will must be unquestioningly obeyed, and without which a girl may not ‘become a woman’, or marry, or perhaps own land.  It is the entry ticket to full adult membership of her community.  FGM in this context is proof of ‘purity’, the essential precursor to being transferred, with due payment, from ownership by a father to ownership by a husband.[11]

To many western or western-oriented/western-educated observers however FGM is the ultimate cruelty, an assault on the body and psyche of girls and women, designed specifically to destroy female sexual pleasure and keep women subservient to men.[12]  For those of us in this second grouping the only possible response to FGM is to seek to eradicate it; and for this reason amongst others many of us insist that the act be named ‘female genital mutilation’.[13]

So what about ‘female cutting’ or ‘female circumcision’?  Don’t they all just mean a ‘custom’?
Why, people often ask, insist on the term ‘mutilation’?  Isn’t it better to use the words ‘cutting’ or ‘circumcision’, the terms frequently adopted by traditional communities?  Isn’t this different tag, ‘mutilation’, disrespectful and unhelpful?

The strongly argued positions behind this debate arise once more from different takes on the practice.  Of course familiar terms will often be used in personal conversation with those directly involved, if survivors (initially victims) prefer a more comfortable term, or in practising communities.

The World Health Organisation, UNFPA and others recommend however that in formal debate FGM be described as what it is: an act which harms and damages the female genital organs, ie genital mutilation.  Medical doctors use euphemisms with patients who prefer that, but in formal discourse the same doctors use precise and explicit terminology.

Nonetheless, some western observers, researchers and analysts persist with naming FGM as, eg, ‘cutting’ (or ‘FGM/C’). Survivors apart, the term ‘cutting’ usually indicates that the observer, most likely an anthropologist,[14] has adopted a relativist perspective; for them empathy with those who practice and uphold FGM outstrips others’ perceived need to speak brutally about a brutal act so that, as that truth gains traction, fewer children will experience it.

Conversely, the FGC contingent claims that in order to stop FGM we must see things through the lens of proponents and perpetrators. For them the distinctions between formal and informal usage are not so critical. Perhaps they lay less emphasis on the necessity to employ explicit terms in dialogue with eg western influencers and policy makers who always also have many demands on their time and resources.

Campaigners who refer to ‘FGM’ are clear that human rights is the fundamental issue.  For them a person’s right to autonomy, including bodily autonomy, is more important that ‘respect’ for historical practices.  Some who avoid euphemisms about mutilation also insist that FGM is not ‘culture’, but rather it is ‘tradition’.  This is the position, for instance, of Dr Morissanda Kouyaté, [15]  the director of the Inter-African Committee on Harmful Traditional Practices,[16] who insists that ‘cultures’ are positive, but ‘traditions’ may not be.

This distinction between customs (to be respected) and traditions (which may need to be abandoned) is helpful in the fight against FGM.

But FGM is a Muslim religious practice; it happens in Africa, not in western societies, so why are we talking about it?
The often heard and connected claims that FGM is a Muslim practice observed only ‘in Africa’ conflates several myths about the practice.

Firstly, FGM is older than any established religion, and it now has practitioners in all of them, as well as in animist and other belief system communities.  Yes, it is prevalent in some Muslim societies, but in fact more people who follow Islam don’t practise FGM than do, and there are many Muslims who don’t even know what FGM is.

Secondly, FGM is defined by history and tradition, rather than religion or faith.   It is attached to the identities of various groupings or tribes, eg crossing national borders in the sub-Saharan belt across the continent of Africa; and it is also performed, often in less publicly, in parts of the Middle East, Asia, South America and Australia.

But FGM doesn’t happen in modern western countries, right?
Sadly, not right. Given the directions in which the African diaspora has moved, FGM now features significantly in Europe and North America, both of which are estimated to have half a million girls and women who have undergone or are at significant risk of FGM.

There are numerous ‘reasons’ why FGM continues even after people leave their country of origin. (Whether it occurs most frequently in the country of origin or of the diaspora is often unclear; every year some children will be sent ‘home’ to be ‘cut’.) Sometimes the practice persists simply because the girls’ new community is closed to new, outside ideas; and, as in the originating communities, sometimes FGM actually becomes resurgent because it is seen as a marker of heritage and identity, sometimes FGM is ‘required’ at the point of marriage, and sometimes girls may be forced or kidnapped by relatives in the country of origin to undergo this harm whilst on a visit not intended by their parent/s to be for that purpose.

And it is probable that, like the Aboriginals in Australia, some North American and European indigenous peoples may have practised FGM at various points in their histories. Indeed, clitoridectomy – also termed ‘female circumcision’ – continued to be carried out (as a ‘treatment’ for masturbation) on white Christian girls in the USA and UK, by white physicians, until the mid-1960s.[17]

Surely trained clinicians – doctor, midwives, nurses and others – would never do FGM?
In fact, they would, and do.  It is thought that about a quarter of all FGM victims / survivors world-wide are now ‘cut’ by clinical personnel – a trend which has produced fierce debate.[18]

Just as traditional birth attendants have for hundreds of years also offered FGM to supplement their income, so do professionally trained clinicians in modern times.[19]  Especially in parts of the world where the salaries of medical professionals are low (if actually paid at all), they can persuade parents – and themselves – that the ‘procedure’ will be safer and less painful in the hands of health practitioners.[20]

FGM medicalization is now the norm in some African countries, such as Egypt,[21] Sudan, and some parts of Kenya[22] and Nigeria, as well as, often very discretely, in various middle-eastern states.  Sadly however there have been several recent global news reports of girls dying even after medicalized FGM.  Perhaps such news stories are driving the practice underground rather than stopping it being done by clinicians.

Perhaps then the answer is to make ‘just a nick’ medicalized FGM legal, to keep it safe?
This idea has gained some supporters who claim that it is possible both to ‘respect’ traditions and make FGM available.  Amongst those organisations which sought to legitimize this position, for a time in 2010 at least, was the American Association of Pediatrics (AAP),[23] but the global medical consensus in both the developing[24] and the first world is now firmly coalesced against the ‘nick’ proposal.[25]

The UNFPA regards the increasing medicalization of FGM as a very serious matter because it is an assault on human rights (and so a breach of medical ethics) and because it appears to give legitimacy to the practice, which in turn can suggests that it has no health hazards and that traditional cutters can also continue with their trade.[26]

Why does male circumcision (MGM) continue, when FGM is so illegal?
This is a good question.

Some anti-FGM activists argue that FGM is a very different matter from MGM, in particular because in some forms it is so severe, and, perhaps more convincingly, because it puts at risk the health of as yet unborn babies, as well as that of the individual who undergoes the original procedure.  (Also, there are probably a few women anti-FGM activists who resent the what-about-ery of some male intactivists, especially in the USA, who protest that MGM is overlooked for FGM…)

Nonetheless, although MGM is ostensibly ‘legal’ in many countries where FGM is forbidden, this does not negate the obvious fact that both are an assault on a child (who cannot give consent) and, as we have seen, both can cause grave ill-health, even death.  More recently however numbers of Stop FGM campaigners[27] have become more direct in speaking out against all genital mutilation – whilst also pointing out that prohibition campaigns must necessarily be different because currently the law is different for MGM and FGM.

It is important to note that male circumcision is, like FGM, a global phenomenon, part of the tradition of both specific religious faiths (Islam and Judaism) and of communities with various belief sets probably going back millennia. What is different is that MGM was in the twentieth century also a customary practice in Christian societies. Particularly, until a few decades ago most men in the USA had been circumcised. Whilst circumcision became mush less common in Europe some while ago (in the UK the National Health Service is reluctant to fund it unless clinically required) it is only recently that fewer than half the male infant population in the USA were routinely cut.

Two observations might arise from this situation.  One is that in places where almost all clinical procedures are conducted as business activity (the customer pays the practitioner direct) there is a clear incentive for said practitioners to recommend any surgery which commands a fee; although even then some practitioners will not offer surgeries that consider potentially harmful or unethical.

The other observation is that in most western countries the senior males who decide the law and policies of their nation have still probably been circumcised.  We might therefore be unsurprised that most of them see no necessity to change legislation; and most likely it also colours their perceptions of at least the less invasive forms of FGM, perhaps throwing some light on the reluctance in some instances to pursue such cases through the courts.

Even cases which reach the courts tolerant reference has occasionally been made to male circumcision as a comparison with FGM.  Should all judges and jurors, one might ponder, be asked to in such cases to bear in mind the potential for any inadvertent bias as a result of their own bodily status, intact or otherwise?       ,

There must be ‘reasons’ why FGM continues. Can’t we just show those reasons are invalid?
Explanations for FGM, everywhere across the globe, vary by time and place; they are rationales for the practice which accommodates different circumstances, usually handed down only by word of mouth, and often in communities where women (and maybe men) cannot read – which enables pretexts to change quite rapidly.  For those directly involved the primary issue is generally that girls must be ‘pure’ (so they can marry with a good bride price), and often ancestors have decreed, with dire threats for any who disobey, that FGM is the proof of that purity.

Whilst such rationales can be challenged by modern western thinking, these challenges will have little leverage in communities where every woman – even if she is actually a young girl – goes through FGM to become marriageable, as the only way to gain the status of an adult.  The persuasive nature of this position has been called a ‘belief trap’.[28]  Who would risk the wrath of the ancestors, or the risk of alienation from one’s community, by not upholding millennia of tradition?

There is a certain irony, it might be said, in the observation that without proactive interventions some girls at risk of FGM are less well served in modern western societies than in traditional locales where properly considered programmes are being introduced to end FGM.  In the west some young women from the diasporas are likely to end up put aside, essentially anomic, as part of an underclass with little influence or control over their lives.[29]

Alternative Rites of Passage (ARPs) are however increasingly gaining traction as ways to empower girls as they progress towards maturity in traditionally practising communities.  ARP programmes[30] seem to work best when there is clarity about the dangers of FGM – respect for persons, but no euphemisms or apologies for the practice – set in the context of bringing the whole community onside.  To be effective, endorsement from group leaders, including the men, must be secured for the messages that women do not need to marry early, and that education rather than premature motherhood will bring better economic and social status returns in the long term.

As yet ARPs are touching just the tip of the iceberg, but slowly the message is getting through in some neighbourhoods. ARPs, allied with newer initiatives to train young journalists such as the Global Media Campaign to End FGM,[31] are also helping to raise awareness by policy makers at community and national levels of the need to end FGM. It is easier for politicians to support interventions when the community has a good knowledge of why that intervention is required.

Nonetheless, in both traditional and western settings, programmes to end FGM are in need of more support at the local level.  National policies are more important than some activists on the ground may think, but the converse also applies.  There can be considerable resentment (and suboptimal efficacy) if those striving to end FGM within local communities are not supported and, importantly, heard, as they should be by those with influence who hold the purse-strings.

This is hypocrisy. You let western women have labiaplasty, but you’ve made FGM illegal.
This might be a good point, but there are two things which weaken this oft-heard criticism:

First, labiaplasty and other female genital ‘cosmetic’ – ie not clinically required – surgery (FGCS) already in some countries can only be performed on consenting adults.  Yes, there are instances in, eg, the UK, of surgery on teenage girls, but it is becoming increasingly clear that this should only be performed in cases of extreme physical or psychological need – and the same requirement or doubts about legitimacy are also often now applied to irreversible transgender surgeries on juveniles.   (In all these contexts the term ‘children’ should ideally reference all people under age 18 regardless of the age of majority in any given country, as at least until this age genitals are in the process of development to their adult form.)

In 2013 the UK Royal College of Obstetricians and Gynaecologists published an ethical opinion paper[32] which explores issues around FGCS and makes recommendations, but it is clear that more research is required before the evidence on the impacts of FGCS are fully understood; the paper also considers suggested parallels with FGM, and concludes that all surgeons must proceed with great care, and ample documentary evidence of informed consent, remaining aware that this is legally an unresolved matter.  These areas of legal ambiguity around FGM, FGCS and specifically juveniles have also been considered in respect of labial surgery in the United States[33] as well as in Australia and doubtless other countries too.

Secondly, and aligned with the position above, FGM is usually performed on young girls who, whatever they say, cannot give legal consent because they are underage; and even those adult women who agree often give their consent under duress (if at all, and they were not kidnapped or whatever).  Thus, FGM is different from FGCS in that the former is normally enforced, and the latter may only be done by qualified surgeons after they have obtained in writing considered, informed consent – although even then it may FGCS is regarded by some professionals as unethical or downright illicit.

A quasi-feasible case could be made by protagonists for permitting FGM and FGCS on adults after fully informed and freely given genuine consent (although this would be extremely difficult in many instances of FGM to establish), but even then the Hippocratic Oath, ‘Do no evil’, raises important questions in regard to what the operator, however skilled, does to her/his patient.

Meanwhile, the ‘accusation’ that FGM is banned hypocritically whilst FGCS is accepted in the West is considerably weakened by the current move in many places towards making FGCS available only under very strictly controlled and/or clinically required conditions.

Nonetheless, professional bodies such as the British Medical Association are clear that more work needs to be done on both the legal and the clinical aspects pf cosmetic surgery.[34] Until a number of questions around these issues have been resolved, some uncertainties will remain.

You mention mental health in regard to genital cosmetic surgery, but what about FGM?
It is of course important to recognise that in western societies a very small percentage – how many, no-one knows – of those who seek FGCS do actually reach the bar for surgical intervention because of psychiatric conditions (eg resulting from body dysmorphia) which are severe enough to justify genital surgery.

But the proportion of women and girls whose mental health suffers following FGM is probably much higher.  This assault on a young person can be seen as a massive breach of trust by those the child depends on in good faith most of all.  If her mother won’t protect her, who will?

The presentation of this distrust is likely to vary by context.  In traditional communities the idea of mental health may not even exist; the well-being of the group eclipses any concern for individuals, but that does not mean no harm has been done; for instance, the condition post-traumatic stress disorder may have as one outcome the formation of tight, inward-looking groups of survivors who find it very difficult to move on from their bonding as people who have experienced something distressing.

This bonding in turn may be an element in the formation of women’s ‘societies’ such as the long tradition of Sande Societies[35] in parts of West Africa, which are predicated on having experienced FGM, and which produce the next generation of cutters and those who run the FGM preparation inductions.[36] The strength of this bonding means it is still very difficult in some locations to dissent from this ‘obligatory’ practice.[37]  In such circumstances it is obviously challenging to find ways to help individuals to move forward, even if they should themselves feel the need, and even if resources to support them are available.[38]

In most western contexts however psychological damage is more readily understood. Girls and women with FGM anywhere in the world may have a range of psycho-sexual and social difficulties arising from their experience,[39] and in locations with mental health facilities these can at least in theory be addressed.  Awareness of this requirement is nonetheless very limited, and much work remains to be done in providing adequate health care, especially psychological, to those who have experienced FGM and need it.

Of course medical care is essential for survivors, but we’ve got laws so can’t we just consign FGM – and child marriage – to history right now?
If only it were that straightforward. Almost everyone agrees that, whilst medical care is critical, the aim must be to prevent FGM, not just treat it after it’s been done.  The contexts in which FGM occurs do are however very difficult to unpick for many reasons.

The law, whilst critical, cannot be enforced without the active consent of a significant proportion of the community wanting it to have effect.  As we have seen, this will is often not the case in regard to eradicating FGM.  There is much work still to be done to ensure that people in practising communities understand both the hazards of FGM, and the opportunities for girls as they reach adulthood uncut.

Child marriage and FGM are closely intertwined in some places, and the idea that there might be other ways than FGM and marriage by which girls can emerge into womanhood is strange, or even threatening, to people in practising communities. There is little or no understanding of the damage which FGM and child / early marriage inflicts, and no notion of womanhood independent of married status.[40] Laws against FGM alone therefore have little impact.

Further, whether in the first world or in developing countries, there remains a big challenge in terms of vocabulary and dialogue in reference to matters genital and sexual. Generally speaking, these matters are not discussed in polite society, and certainly not by men.  A lot of groundwork is therefore required before law enforcers (usually male) may feel comfortable talking, or even just carefully considering, ‘delicate’ issues such as young girls’ forthcoming sexuality – and this also holds true across the board for many social workers, teachers and others with responsibility for safeguarding.[41]  There are many obstacles at ground level to effective policing and prevention.[42]

There are also frequently difficulties around cross-border issues.  Traditional communities may claim to have abandoned FGM, only to go to the next village, across a state boundary, to cut with impunity.  Likewise, in western societies, international and inter-state vigilance is required.  This applies whether in Europe (where the probably forthcoming Brexit situation makes things even more complicated) or in eg the United States, where federal enforcement has a different status than state administrations.

We do however know that when the courts find cutters guilty this can have an impact on practising communities.  One example of this is France, where the barrister Linda Weil-Curiel and her colleagues have insisted that trials be conducted in the highest courts, and that penalties are significant.[43]

Clearly men are important re law enforcement, but otherwise isn’t FGM a ‘women’s problem’?
It’s understandable that observers conclude that, because women usually do the actual FGM cutting, stopping FGM must be up to the women. This belief does not however bear up under scrutiny.

Research in many places has shown the financial considerations around FGM in local economies, and for families. Often, the practice is timetabled for harvest time and the ceremonies cost a lot of money.  The expenses are likely to be the responsibility of the girls’ fathers, who expect that their investment (in the ceremony and in bring the girl up) will be repaid in bride price or dowry when local suitors select their post-FGM bride.  Men effect, and sometimes genuinely have, little knowledge of exactly what happens in FGM, but they are the ones who likely will gain money from it afterwards.

Further, senior men (often especially clerics) in the community are the ones who make most of the rules.  If they cannot be persuaded that FGM must stop, it probably will not.

FGM and other harmful traditional practices will only cease when everyone in the community, men and women, girls and boys, recognises that it must do so.  Education, health care, legal enforcement and, to ensure people know about public health and court decisions, the media, all have a part to play in ending FGM.

So what else do we need to know?
The essential message is that FGM is a tradition which harms both individuals and the communities on which it impinges.

FGM is a particularly toxic form of patriarchy incarnate; in the end it benefits no-one, neither those who are harmed, nor those who inflict it, nor the communities in which it is practised.

Also, FGM is deeply rooted in the economy and economics.[44]  It will only stop when there are other ways to provide women ‘cutters’ with income, and when, just as with human trafficking etc, the costs to all who do it outweigh the profits.

And finally, eradication will depend on co-ordination across many different agencies and interests. A piecemeal approach will produce piecemeal, unsatisfactory, results. This means that someone or some organisation must take ultimate responsibility for stopping FGM; a multi-agency approach alone will not deliver eradication.

Politically, it is essential that a senior minister in government is the named person who carries the can for eradicating FGM and other harmful practices.  The pretence that a number of ministers can be equally responsible means that true accountability is avoided.

But there is also a need to streamline decisions and operations in practical terms. Many will have a part to play in this, but public health is the discipline and agency which can best bring together all the elements and tools of eradication.[45]

Whether the challenge is sexual abuse, knife crime, early or forced ‘marriage’, or FGM, public health has the potential to synchronise and deliver the required elements of prevention, legal, educational, clinical, community and so forth.

The drama of the high court is one critical aspect of making FGM stop, and the cerebral endeavour of legislators is another, but the day-to-day efforts of public health workers from many disciplines and with many different contacts and skills, are what will create the momentum to make FGM history in communities everywhere.

[1] See WHO for an overview of what FGM comprises: http://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation

[2] The clitoris is actually quite a large wishbone-shaped organ which surrounds the vagina, but only the front ‘button’ is visible . An interesting exploration of misunderstandings of the clitoris, and of the patriarchal intent behind its excision, can be found here: https://www.researchgate.net/publication/319382653_The_Clitoris_Anatomical_and_Psychological_Issues

[3] See   http://www.who.int/reproductivehealth/topics/fgm/health_consequences_fgm/en/   and http://www.cirp.org/

[4] The main causes of obstetric fistula are very young ages to have children, and obstructed, mostly unsupervised childbirth in non-clinical settings.  The evidence that FGM causes some fistulae is till disputed  http://www.endfistula.org/what-fistula but increasingly some researchers insist that there is sometimes a direct connection https://www.popcouncil.org/uploads/pdfs/2017RH_FGMC-Fistula.pdf .  It has been suggested that disputes about FGM as potential causation may on occasion relate more to political considerations than to medical ones.

[5] http://www.who.int/bulletin/volumes/86/9/08-051482/en/

[6] See https://www.jstor.org/stable/10.7722/j.ctt6wp8c1 (and a critique: http://thecircumcisiondecision.com/circumcision-death/ )

[7] See eg http://www.intactamerica.org/

[8] An infant or child in a traditional community whose mother dies may be in particular peril, see eg https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4423767/ and https://www.researchgate.net/publication/279062829_The_Effects_of_Maternal_Mortality_on_Infant_and_Child_Survival_in_Rural_Tanzania_A_Cohort_Study

[9] See eg https://www.28toomany.org/blog/2016/may/16/the-psychological-effects-of-female-genital-mutilation-research-blog-by-serene-chung/ and https://ratical.org/ratville/MGMprimer.html

[10]https://www.preventioninstitute.org/sites/default/files/publications/Adverse%20Community%20Experiences%20and%20Resilience.pdf

[11] who may well already have other wives amongst whom there is a pecking order

[12] For this reason I have coined the term ‘patriarchy incarnate’ – the literal infliction of their will by some men on the bodies of women – to characterise the acts of FGM, forced and early marriage, and other harmful traditional practices: https://hilaryburrage.com/2016/03/05/patriarchy-incarnate-the-horrifying-practice-of-female-genital-mutilation

[13] See eg https://statementonfgm.com/

[14] Tobe Levin von Gleichen has named these relativist anthropologists as ‘anthr/apologists’.

[15] See the Preface to Female Mutilation (Burrage, New Holland Publishers, 2016) http://uk.newhollandpublishers.com/fm_preview.pdf

[16] http://www.soawr.org/content/inter-african-committee-harmful-traditional-practices-iac

[17] This is one first-hand account: https://www.theguardian.com/us-news/2016/dec/02/fgm-happened-to-me-in-white-midwest-america

[18] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5840226/

[19]https://www.28toomany.org/static/media/uploads/Thematic%20Research%20and%20Resources/Medicalisation/medicalisation_of_fgm_(april_2016).pdf

[20] https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-017-0306-5

[21] https://www.egyptindependent.com/cut-secret-medicalization-fgm-egypt/

[22] https://www.nation.co.ke/health/Emerging-trends-in-FGM-Cross-border-cutting-and-medicalisation/3476990-4583890-gffermz/index.html

[23] And more recently for instance some Boston USA physicians

[24] https://www.sciencedirect.com/science/article/pii/S1110570413000271

[25] https://www.popcouncil.org/uploads/pdfs/2017RH_MedicalizationFGMC.pdf

[26] https://www.unfpa.org/resources/brief-medicalization-female-genital-mutilation

[27] such as Dr Tobe Levin von Gleichen

[28] See Gerry McKie: https://www.jstor.org/stable/2096305?seq=1#page_scan_tab_contents for further discussion of this ‘belief trap’ – though the parallels between ending FGM and ending footbinding are to some observers less convincing.

[29] https://hilaryburrage.com/2014/04/24/does-female-genital-mutilation-fgm-in-western-societies-create-an-underclass/

[30] Eg https://pastoralistchildfoundation.org/

[31] Of which this writer is a non-executive director: https://www.facebook.com/gmcendfgm/

[32] https://www.rcog.org.uk/globalassets/documents/guidelines/ethics-issues-and-resources/rcog-fgcs-ethical-opinion-paper.pdf

[33] http://news.trust.org/item/20160526125209-vxc3f

[34] https://www.gmc-uk.org/-/media/documents/guidance-for-all-doctors-who-offer-cosmetic-interventions—published-version_pdf-69113414.pdf

[35] http://www.refworld.org/docid/58cff6114.html

[36] A description from 1949  of the Sande (women) and Poro (male) societies in Sierra Leone gives a good idea of how important these organisations have been in the communities in which they exist: https://anthrosource.onlinelibrary.wiley.com/doi/pdf/10.1525/aa.1949.51.2.02a00020

[37] https://www.theguardian.com/global-development/2015/aug/24/sierra-leone-female-genital-mutilation-soweis-secret-societies-fear

[38] https://www.tandfonline.com/doi/full/10.1080/23311886.2017.1295549

[39] https://www.28toomany.org/blog/2016/may/16/the-psychological-effects-of-female-genital-mutilation-research-blog-by-serene-chung/

[40] These views of marriage – which are also the rules both for power and for inheritance – also go some way to explain the hostility to (or sheer ignorance about) homosexuality and other non-married states.

[41] https://hilaryburrage.com/2016/11/25/white-ribbon-day-and-what-we-can-learn-from-men-who-challenge-fgm/

[42] https://hilaryburrage.com/2016/06/08/policing-issues-in-regard-to-female-genital-mutilation-in-the-uk/

[43] https://hilaryburrage.com/2012/11/28/the-uk-can-learn-from-france-on-fgm-prosecutions/

[44] https://hilaryburrage.com/2017/11/23/economics-is-why-fgm-persists-oxford-seminar-on-the-elephants-in-the-room/

[45] https://hilaryburrage.com/2018/04/24/the-many-es-of-fgm-eradication-and-why-they-all-lead-via-economics-and-epidemics-to-public-health/

Your Comments on this topic are welcome.  
Please post them in the box which follows these announcements…..

~ ~ ~ ~ ~

Books by Hilary Burrage on female genital mutilation

https://orcid.org/0000-0002-6684-2740

Eradicating Female Genital Mutilation: A UK Perspective (Hilary Burrage, Ashgate / Routledge 2015).
Full contents and reviews   HERE.
 
FEMALE MUTILATION: The truth behind the horrifying global practice of female genital mutilation  (Hilary Burrage, New Holland Publishers 2016).
Full contents and reviews   HERE.

FURTHER INFORMATION AND ACTION

There is a free FGM hotline for anyone in the UK: 0800 028 3550, or email: fgmhelp@nspcc.org.uk

Details of NHS Specialist Services for FGM here.

More info and posts on FGM here.

Activists, service providers and researchers may like to join the LinkedIn group Female Genital Mutilation (FGM): Information, reports and research, which has several hundred members from around the world.

The (free) #NoFGM Daily News carries reports of all items shared on Twitter that day about FGM – brings many organisations and developments into focus.

Also available to follow at no cost or obligation is the #NoFGM_USA Daily News.

Twitter accounts:          @NoFGM_UK  @NoFGMBookUK @FemaleMutlnBook  @FGMStatement  @NoFGM_USA @NoFGM_Kenya  @NoFGM_France  @GuardianEndFGM [tag for all: #NoFGM] and @StopMGM.

Facebook page: #NoFGM – a crime against humanity

Email contact: via Hilary

.

[NB The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, which has a primary focus on FGM, is clear that in formal discourse any term other than ‘mutilation’ concedes damagingly to the cultural relativists – though the terms employed may of necessity vary in informal discussion with those who by tradition use alternative vocabulary. See the Feminist Statement on the Naming and Abolition of Female Genital Mutilation,  The Bamako Declaration: Female Genital Mutilation Terminology and the debate about Anthr/Apologists on this website.]