World health jonlm, 3 (4): 391-394 (1982)
In Focus Fawzia Assaad
The sexual mutilation of women Efforts are now being made to eliminate the age-old custom of female circumcision. But the practice is deeply rooted in cultural and religious tradition.
The origins of clitoridectomy are shrouded in mystery, and it is no less puzzling why the practice continues to exist today. This genital mutilation causes great pain to the girls subjected to it, and it is well known to be harmful both bodily and mentally- sometimes, indeed, fatal. Yet the custom stubbornly persists across great areas of Mrica. Two works published in recent years have focused attention on the practice of female sexual mutilation and the struggle to bring it to an end. One, entitled Against the mutilation of women: the struggle against unnecessary suffering, was written by Lilian Passmore Sanderson, an Englishwoman who lived and worked for many years in the Sudan (1). The other, Female circumcision, excision and infibulation: the facts and proposals for change, was compiled from various reports by Scilla McLean on behalf of the Minority Rights Group, an international research and information organization (2).
moval of part or all of the clitoris and the labia minora. In Mali and Sudan, girls are also subjected to infibulation 1 -the almost complete removal not just of the clitoris but also of the labia minora and majora, following which the vagina is sewn up to leave only a small opening. A map of Africa showing the geographical distribution of the practice of female sexual mutilation indicates that some form of the custom has been reported from places in a continuous belt crossing the middle of Africa from west to east and continuing down the Nile. But one of the people I consulted, Isabelle Tevoedjre, Coordinator of the Working Group on Female Circumcision,2 expresses doubt that the practice exists in Benin (her country), Togo, and the Ivory Coast, except among a few northern tribes, or in Niger, except near the border with Mali and the Upper Volta. The estimated number of mutilated women might also be questioned. Scilla McLean gives the figure of 74 million, citing as her source 1 The word infibulation comes from an old Roman custom in which the foreskin of a male slave or the vagina of a female one was "muzzled" by a ring, or fibula, to curb sexual activities and prevent unwanted pregnancies. Infibulation is also known as "pharaonic circumcision". 2 Nongovernmental organizations providing assistance in health education campaigns may be contacted through the Working Group, care of Ms Tevoedjre, 17, chemin des Ramiers, 1245 Collonge-Bellerive, Geneva, Switzerland.
Description and Distribution The custom varies from area to area. In some places the mutilation is confined to circumcision-the removal of part or all of the clitoris. Elsewhere excision is practised -the re-
Or Assaad has taught philosophy at Ain Shams University, Cairo, Egypt. She is the author of numerous essays on philosophy and of a novel L 'Egyptienne, published in 1975 by Mercure de France, Paris.
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Fran Hosken, whose report on the subject has been published by the Women's International Network News. 3 Lilian Passmore Sanderson is more cautious, giving several hypothetical estimates : 20 or 65 or 75 million. But what does it matter? The fact is: female mutilation is practised, and widely.
feast that accompanied their excision or infibulation as a great event in their community and as an initiation experience that ushered them into the adult world in an aura of tradition and celebration. It is these women who keep the custom alive.
Health Considerations Both of the cited books stress the physical and psychological effects of female genital mutilation, which include infections, tetanus, oedema, and dermoid cysts of the vulva. The narrow aperture of an infibulated vagina can cause many complications : the menstrual blood may coagulate; obstruction to the flow of urine can lead to infection or septicaemia; childbirth is often complicated, incision of the vulva generally being necessary; and fistulas may form, linking the vagina to the rectum or urethra. And then there are the fear, shock, and pain associated with the procedure, which can leave permanent emotional scars. Obviously, the communities are aware of these effects. They try to counteract them in their own way, making the procedure an occasion for feasts, the giving of gifts, fumigation with incense, the
Historical and Cultural Aspects What is the reason for these mutilations? Is it a matter of aesthetics? Does it give the husband greater sexual pleasure? The Arabic word tahara, meaning purity or cleanliness, has a subsidiary meaning of " circumcision, male or female". In what sense should this be understood? The beauty and cleanliness of the genitalia? Protection against excesses in very hot countries where family honour depends on the virginity of the woman? Or protection against venereal diseases or illegitimate births? None of theses reasons is valid. Traditionally, in societies in which clitoridectomy or infibulation is practised, a girl who has not been subjected to the procedure will not find a husband. Yet some of the men who have been questioned about their preferences claim to experience more pleasure and fewer complications with a woman who has not been mutilated. Moreover, the infibulated vagina provides no guarantee of virginity or chastity. Why, then, these mutilations? There is a widespread belief that the practice is advocated by the Islamic religion, but this reflects a fundamental misunderstanding. Actually, female circumcision was common in pagan times. The Greek historian Herodotus, in the fifth century B.C., mentioned that it was practised among the Phoenicians, the Hittites, the Ethiopians, and the Egyptians. Why it was practised is not known. Female circumcision is never mentioned in the Koran; but oral tradition does supply some support for its association with Islam. Ibn El Athir quotes the Prophet as saying, "Circumcision is compulsory for men, honourable for women". The sunna, or traditional excision, involves only partial removal of the clitoris ; further cutting would be reprehensible in view of Muhammad's advice to the traditional practitioner Om Atteya: "Circumcise, but do not go too far. It looks better and gives the husband more pleasure".
Traditionally, in societies in which clitoridectomy or infibulation is practised, a girl who has not been subjected to the procedure will not find a husband.
wearing of amulets, and various other rituals. These do not, however, allay the adolescent girl's anxiety as marriage approaches. There is fear of pain; often sexual harmony is disrupted, and this can lead to sterility and divorce. Some infibulated women have experienced few or none of these psychological traumata and do not associate any relevant physical disorders they may suffer with the fact that they were mutilated. They remember instead the 3
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In the course of history, Islamic religious leaders have adopted dogmatic and contradictory positions on the subject. At the turn of the twentieth century in Sudan, they held that pharaonic circumcision was an integral part of Islamic tradition. In 1939 the Mufti of the Sudan condemned pharaonic circumcision, but authorized the sunna. In 19 51 the Grand Mufti of Egypt, Fadilat Allam bey Nassar, recommended the sunna as a means of moderating and controlling women's sexuality. Future stands of religious leaders will doubtless depend on whether their convictions are modernist or fundamentalist, and varying interpretations are obviously still quite possible.
subject of female circumcision, and all the participants from countries in the Organization's African and Eastern Mediterranean Regions unanimously resolved that the practice in all its forms should be abolished (3, p. 12). In March 1980, WHO and UNICEF jointly decided that two essential principles should guide their action with regard to this sensitive issue, namely, that they should involve national govern-
Efforts to Eliminate Female Mutilation Lilian Sanderson's book presents a detailed and highly significant account of the campaign waged against the practice by missionaries and colonial authorities in Egypt, Kenya, and the Sudan. They encountered obdurate resistance. In Egypt, the Jesuits tried to intimidate the Copts who had converted to Catholicism by threatening them with excommunication if they practised female mutilation; but since the Copts then proceeded to marry non-Catholic women who had been subjected to the procedure, the Church abandoned its threat. In Kenya the Church of Scotland tried different sanctions, such as expulsion from school. But with the awakening of nationalism, Christianity was equated with colonialism, and the missionaries' policies, in all their forms, were opposed. In fact, following independence, the campaign against the practice was considered a threat to national solidarity and interference in the social and cultural life of the country. What lesson should be drawn from this striking historical picture? One of non-intervention, or one of discreet action? The publicity given to the crusade against sexual mutilation has certainly not been discreet, but one has to admit that it has made the W otld Health Organization break its long and cautious silence. In early 1979, in anticipation of the 1980 World Conference of the United Nations Decade for Women, two whole days of a WHO Seminar on Traditional Practices Affecting the Health of Women and Children, held in Khartoum, Sudan, were devoted to the
It is to the villages and rural areas especially that the fight to eliminate the practice of female sexual mutilation has to be taken.
ments, and that they should integrate the fight against the practice into the overall primary health care programme. Last but not least, Kenya outlawed the practice on 26 July 1982; President Moi declared publicly that it made fear grow in children and retarded their mental development. Still, those deeply concerned about the issue say that thus far there have been only declarations of intent; there has been no real action. It may be that some countries are finding it hard to get/rimary health care programmes off the groun and that national ministries find it easier to allocate funds to a Western-type medical system that serves mostly urban dwellers. But it is to the villages and rural areas especially that the fight to eliminate the practice of female sexual mutilation has to be taken; preaching to the already converted in modern cities will not serve the purpose. It is often claimed that the problem of female mutilation is very low on the list of government health priorities, that providing clean drinking-water and elementary hygiene is far more urgent. It should be realized, however, that regardless of the priority accorded it, eliminating this harmful practice would produce savings in national budgets. In May 1979, the late Dr A. H. Taba, then WHO Regional Director for the Eastern Mediterranean, drew 393
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attention to the cost to the health services of complications of female circumcision in terms of just one hospital in the Region: 196 7 days of hospitalization between July 1977 and July 1978 (3, p. 10). The report of the Minority Rights Group lists a number of national projects and government-appointed commissions endeavouring to integrate the campaign against female genital mutilation into rural development or primary health care programmes -in Egypt, Kenya, Somalia, and the Sudan, for example. These programmes need the wholehearted and combined efforts of international organizations and of national ministries responsible for health, education, and information. Legislation is envisaged. But what use are laws without agencies to enforce them? In 1975, mass information campaigns by radio in Upper Volta, reaching the most remote villages, produced hostile reactions. Although the support of religious authorities may be desirable, it could mean treading on dangerous ground: current fundamentalist tendencies might give rise to an interpretation that would not be in the interests of health. Female mutilation is pre-eminently a health problem, and must be treated as such. And let no-one say that it should not be placed at the top of the list of priorities. It is a question of needless and costly suffering, the repercussions
of which are difficult to assess because of the silence that surrounds it. A certain modesty prevents people from talking about it. Those who raise their voices to the point of offending that modesty may attract a certain amount of resentment but they will find many allies and may eventually compel the authorities to act. It is time for national governments to take a stand on the issue, to act promptly and discreetly, by making the campaign against female mutilation an inherent part of programmes to improve maternal and child health through primary health care and health education of the public. The difficulties are enormous. But the problem must be tackled. D REFERENCES
of women: the stf'llggle against unnecessary suffering. London, Ithaca Press, 1981 (obtainable from Ithaca Press, 13 Southwark Street, London SE 1, England, price£ 2.50). 2. McLEAN, S. Female circumcision, excision and infibulation: the facts andproposalsfor change. London, Minority Rights Group, 1980 (Report No. 4 7) (obtainable from Minority Rights Group, 36 Craven Street, London WC2N SNG, England, price£ 1.20 plus 30 p surface mail). 3. World health, May 1979. 1. SANDERSON, L. P. Against the mutilation
Illiteracy- an aspect of culture Being unable to read and write is not merely a result of educational lacunae. lt is, rather, symptomatic of cultures which are non-literate; where neither the written word nor literacy skills are normative, required, or appreciated. Knowledge, attitudes, and skills held important by such cultures are transmitted from generation to generation through welldeveloped socialization patterns and instructional methods, and do not include literacy. Not uncommonly, schoolleavers and literacy programme graduates are found to have relapsed into illiteracy. - David Harman, UNICEF news, Issue 112, 1982, p. 3.
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