What is Female Genital Mutilation?

Female genital mutilation is a procedure on the external female genitalia without any medical necessity.

Variation

Female genitalia can be mutilated in a number of ways. Which parts of the genitalia will be mutilated, and the extent to which this occurs, depends on the local customs, the wishes of the parents and the circumciser.

Forms

The World Health Organization (WHO) distinguishes four types of female genital mutilation (see also these drawings on Wikipedia).

Type 1:

Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).

Type 2:

Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).

Type 3:

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).

Type 4:

All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.

The most dramatic form of FGM is type 3. This form usually causes the most health problems..

FGM or girl circumcision?

The term preferred by the WHO is female genital mutilation. The Dutch government rejects the term girl circumcision, because it, like the WHO, considers the practice to be a form of mutilation. Therefore, in all official documents for policy makers, policy implementers and care providers in the Netherlands the term ‘vrouwelijke genitale verminking’ (female genital mutilation) is used.

However, in direct contact with people from the communities at risk of FGM, professionals are advised to talk about girl circumcision. In such conversations it is of great importance to build a relationship of trust. Thus, it is useful to use a non-judgmental term.

Terminology

Different terms are used for the practice of girl circumcision. In English-speaking countries people use the terms female genital mutilation (FGM), circumcision, cutting or female genital cutting. In French-speaking countries, the terms ‘mutilation genital feminine’ or ‘excision’ are used.

In the Netherlands, in the past we mainly used the term ‘vrouwenbesnijdenis’ (female circumcision). Meanwhile, this has been replaced by ‘vrouwelijke genitale verminking’ the literal translation of female genital mutilation. As the practice is usually carried out at a young age, the term ‘meisjesbesnijdenis’ (girl circumcision) is also common.

Below is a list of commonly used terminology regarding FGM. Some terms have multiple meanings and are therefore confusing. It is thus important to always ask what someone means when using a specific term.

  • Sunna

    1. A mild form of FGM, such as pricking the clitoris until a drop of blood appears (type 4)
    2. A collective term for all forms of FGM
  • Reversal operation

    1. Deinfibulation
    2. Reconstructive surgery: a surgical procedure in which the clitoris is dissected and the labia minora and/or labia majora are recreated
  • Reinfibulation

    The re-suturing of the remaining parts of the labia, particularly after childbirth, so that the vaginal opening is reduced to its initial size before the deinfibulation

  • Recutting

    1. Reinfibulation
    2. From a milder to a more severe form
    3. Around eight weeks after a first circumcision, in case this has not been done properly
  • Reconstructive surgery

    A surgical procedure in which the clitoris is being dissected and the labia minora and/or labia majora are recreated

  • Infibulation

    Narrowing of the vaginal opening by cutting away and stitching together the labia minora and/or the labia majora, with or without removal of the clitoris (type 3)

  • Excision

    Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (type 2)

  • Deinfibulation

    A procedure in which the vaginal opening is increased, by cutting the scar tissue between the (former) labia and stitching the cut surfaces in such a way that they are no longer able to grow together; this is usually done before a woman is getting married or giving birth

  • Clitoridectomy

    Partial or total removal of the clitoris and/or the prepuce (type 1)

Prevalance

According to a study done by Pharos in collaboration with the Erasmus Medical Centre in Rotterdam, the Netherlands (2013) an estimated number of 40 to 50 girls living in the Netherlands are circumcised annually. An estimated 29,000 women in the Netherlands have already been circumcised. Eighty percent of these women originate from Somalia, Egypt, Ethiopia, Eritrea and the Kurdish autonomous region in Iraq. Most of them are between 20 and 49 years old. Starting at the end of 2017, Pharos is repeating the prevalence and incidence study that was conducted in 2013. The results are expected to be released halfway through 2019.

Female Genital Mutilation in the Netherlands. Prevalence, incidence and determinants(Pharos, 2013)

On January 1, 2014, there were around 97,000 women from the so-called risk countries in the Netherlands, of whom 38,000 were younger than 18 years (source: Central Bureau of Statistics, the Netherlands). Risk countries are countries of which we know that FGM is practiced, because data are available.

Risk assessment

Below you find an overview of the number of women and girls originating from risk countries who are living in the Netherlands. To estimate whether they are at high or low risk of FGM, Pharos looks at the prevalence rates in the countries of origin. These figures are averages and should be interpreted with caution: there can be large regional differences within countries, and migration may affect the decision whether or not to circumcise.

Women living in the Netherlands, originating from risk countries

Women and girls originating from risk countries who are living in the Netherlands
Country of originTotal number of women  (a)Of whom girls aged 0-18 yrs
(a)
Prevalence in country of origin (b)
Benin166757%
Burkina Faso26312876%
Central African Republic341024%
Chad531644%
Congo (Democratic Republic)4.1231.620
Cote d’Ivoire81436438%
Djibouti1175393%
Egypt8.5833.76291%
Eritrea1.26645589%
Ethiopia6.0211.84574%
Gambia44622876%
Ghana11.4523.7044%
Guinea1.76483396%
Guinee-Bissau1635150%
Iraq24.1818.0278%
Kenya2.09077727%
Liberia1.30962958%
Mali1637889%
Mauritania845169%
Niger115502%
Nigeria5.5342.53027%
Senegal72533926%
Sierra Leone2.3051.07788%
Sudan, North (c)2.5101.11288%
Somalia17.8338.20898%
Tanzania1.07645615%
Togo7643274%
Uganda1.0213181%
Yemen27713038%
Totaal96.71937.838
a) Dutch Central Statistical Office, 1 January 2014
b) Population Reference Bureau, Fgm/c: Data and trends, update 2014
c) Circumcision: Population Reference Bureau, Fgm/c: Data and trends, 2008

Previous research on FGM in the Netherlands

Two other studies were conducted on the prevalence of FGM in the Netherlands:

  • In 2005, the Board of Health (RVZ) investigated whether girls were being circumcised in the Netherlands. The study focused on girls who had migrated from risk countries to the Netherlands. This small study showed that FGM does occur in the Netherlands. The RVZ estimated at the time that at least 50 girls were being circumcised in the Netherlands each year.
  • In 2008, TNO did a retrospective study on the prevalence of FGM in all midwifery practices. This study showed that 4 out of 10 pregnant women from risk countries who give birth in the Netherlands were circumcised.

Background

Reasons for FGM

The circumcision or cutting of the external genitalia of girls is a cultural tradition that is connected to notions of cleanliness, beauty, femininity and sexual morality. The reasons parents are giving for circumcising their daughters, vary from family to family and from community to community. Typically, this is done to protect the social status of the family and to increase a girl’s chances of finding a marriage partner. This way, parents try to secure the future of their daughters. Marriageability, therefore, is an important factor.

Parents’ decision to circumcise a daughter is also influenced by the prevailing social norms: people feel compelled to have their daughters circumcised, because others have also done so. Many girls and women take FGM for granted: it is part of life, after all everyone is circumcised. Local power structures – from community and religious leaders to women who perform circumcisions – are playing a major role in continuing or eliminating this tradition.

Practicing communities often cite the following reasons for FGM:

  • It increases a girl’s marriage chances.
  • It protects the virginity of the girl.
  • It provides status in the community.
  • A circumcised woman is seen as beautiful.
  • It is a sign of a good upbringing.
  • It is a cultural tradition.
  • It is a religious requirement.

Age

FGM usually takes place between the ages of 4 and 12. But in some cultures, baby girls are already being circumcised a few days after birth. Also, FGM may take place just before a girl’s wedding. As a result of migration, circumcision may take place at a different age than considered normal in the culture of origin.

Organization

A circumcision can be organized for one single girl, but sometimes all the girls of the same age in a particular village are being circumcised at the same time. Traditionally, a circumcision is performed outside the clinic, without anaesthesia and under non-hygienic conditions, by local midwives or by other women who have not received any medical training.

However, the WHO has reported an increase in the number of girls who are being circumcised in a hospital, under anaesthesia, by trained health providers. This type of medicalization takes place in particular in countries like Egypt, Sudan and Kenya. This is often done to guarantee hygienic circumstances. (Source: Female Genital Cutting: The Interpretation of Recent DHS Data, USAID, 2013)

Origin and religion

The exact origin of FGM is not clear. In Egypt, mummies have been found of circumcised women dating from 2000 BC. The tradition is often associated with Islam. However, FGM is not mentioned in the Quran as a religious requirement, nor in the hadith.

There are countries where Islam is the main religion but where FGM does not occur. Furthermore, FGM is also practiced by (Coptic) Christians and animist communities. In some regions, this pre-Christian and pre-Islamic practice has become intertwined with religion.

Quran and hadith

Although FGM is not mentioned in any religious writings, some people see it as a religious requirement. Especially the relationship with Islam is often mentioned. According to some Muslims, an important motive for the continuation of female genital mutilation is that one hadith prescribes that it is ‘sunna’ to circumcise your daughters. Sunna here refers to ‘exemplary behaviour according to the Prophet.’

The hadith that possibly speaks about FGM states: ‘Touch, but do not take anything away,’ which is sometimes interpreted as: ‘Do not cut too deep.’ This hadith is interpreted differently by different people, also by Quran scholars. According to a Somali religious leader, Imam Yusuf Adan, it is therefore not logical to follow this weak hadith. Female genital mutilation is certainly no obligation for a Muslim, because it is not mentioned anywhere in the Quran.

Fatwas against female genital mutilation

Globally, major Islamic religious leaders have issued several fatwas against FGM. Also, at a symposium held in 2007, Dutch imams signed a statement expressing their commitment to be actively involved in the fight against FGM in the Netherlands.

During this symposium, Dr. Abbas Khadar of the Al-Azhar University in Cairo was present. This religious leader represented the highest Islamic cleric of Egypt, Professor Dr. Ali Goma’a, who in November 2006 had pronounced a ban on FGM for Muslims and had called on them to end this practice.

Overview of some fatwas

Health effects

Female genital mutilation can cause physical, psychological and sexual problems. There is a high probability these problems will occur, both shortly after surgery and in the long term. Most problems develop after an infibulation. When they have FGM-related problems, women and girls do not necessarily relate these to their circumcision.

Physical effects during and immediately after the procedure

  • Extreme pain (in case the procedure takes place without anaesthesia)
  • Complaints of the urinary tract (painful urination, accumulation of urine in the bladder)
  • Excessive bleeding
  • Risk of infection (locally, possibly with ulcer formation, but also hepatitis, HIV, and tetanus)
  • Shock
  • Death

Consequences in the longer term

Physical

  • Menstrual problems
  • Painful or impossible sexual intercourse
  • Painful and/or difficult urination
  • Urinary tract infections
  • Chronic pelvic pain
  • Chronic infections
  • Having difficulty getting pregnant
  • Scarring
  • Vaginal stones
  • Increased risk of HIV infection
  • Difficult internal examination (smear test)
  • Difficult childbirth
  • Medical intervention to enable sexual intercourse and childbirth

Psychosocial and sexual

  • Anxiety and depression
  • Post-traumatic stress disorder (PTSD)
  • Fear of sexuality
  • Negative impact on sexuality
  • Negative impact on physical sexual response in women

Read the article Local customs but a global issue: the case of female genital mutilation

Factors that play a role in the development of psychological complaints

  • Form of FGM
  • The age at which a girl was circumcised
  • Conditions under which the circumcision was carried out (with or without anaesthesia, location, etc.)
  • Conviction: how do the parents and the girl herself feel about circumcision?
  • Culture: how openly do people talk about FGM?
  • Migration to countries where circumcision is forbidden
  • Attitude of the spouse/partner with regards to sex
  • Substance use (including khat)

Read more about the psychosocial consequences of FGM in the book Veiled Pain (Pharos, 2010)