Female Excision Research Paper

There are at least four major forms of excision. In the mildest form, the clitoris is barely nicked or pricked to shed a few drops of blood. The second kind which is often called sunna involves the removal of the clitoral prepuce, hood, or outer skin. The third gradation, clitoridectomy, more accurately describes the process of excision. Here, the clitoral glans and some of the nympha or labia minora—the narrow liplike enclosures of the genital anatomy, are severed. Infibulation is the least popular and most extreme procedure; it entails scraping the labia majora—the two rounded folds of tissue that contour the external boundaries of the vulva, and stitching the remaining raw edges together in a manner that reduces the vulva opening after the surgery heals. Different forms of the operation affect the genitalia differently.

2. Rationales

Nobody can unequivocally identify where, when, or why excision originated. The practice can mean different things to different actors in different milieus. Embedded in an intricate web of habits, attitudes, and values, excision has both functional and symbolic connotations. It is validated and undergirded by a spectrum of temporal and spiritual beliefs. While some of the justifications are at odds with ample medical knowledge, efforts to counter the practice by illuminating the medical contradictions have not been very successful in eroding commitment to it. This is mainly because, for adherents, the attraction and imperative of the practice has little to do with medical science. Recurring themes such as sexuality and fertility signify and affirm paramount indigenous values like solidarity, public recognition of lifecycle change, and procreation for social continuity. That it deals with the genetalia and is suffused with gender constructs does not denote unequivocally exclusive or primary concern with gender and sexuality.

Among the Sande for example, it has been reported that initiates spend months in seclusion being instructed on topics as broad as the cultural secrets of successful living and traditional medicine. With the Chagga, excision is said to test courage by simulating birth labor pains. To the Mende and Sherbro, it fosters cooperation among women. The Bambara and Mossi assume it reduces mortality and morbidity. Some Bantu and Sudanese use it for purification. In other areas, excision is employed as a means of self-definition, self-assertion, and expression of personhood and identity; it has also been characterized as the equivalent of an ornamental tatoo, or a kind of cosmetic surgery akin to ear-piercing. On a continuum with these worldviews are a competing set of beliefs which tend to emphasize the dimensions of sexuality and gender. But even these beliefs are tempered and nuanced in the manner in which they inform everyday realities.

The Mandingo, Massai, and Swahili believe that excision renders the body fertile and fit for the social order. Among some Yoruba it is considered a contraceptive device. In some other groups, excision reflects a fear of a primal hermaphroditic human nature and an attempt to differentiate the sexes. Still others justify it on grounds of aesthetics; to these, unaltered female genitalia are unsightly, and occluded or attenuated body orifices are more preferable. Some communities subscribe to the belief that a girl is ripe for sexual relations only after being ushered into womanhood by circumcision. Finally, there are communities that, to enforce moral values and ethical standards, discourage premarital sex. These groups believe that circumcision attenuates sexual desire and this mindset underscores its incorporation as a rite of passage. Regardless of the prevalence of this mindset in select groups, excision does not necessarily encode absolute prenuptial chastity nor does it prima facie signal a distortion of women’s sexual experiences. From all indications, the practice is not homogenous; it has divergent contexts, meanings, and consequences. However, some opponents of the practice insistently explain it monolithically to privilege connotations of sexual politics and patriarchal control.

3. Emerging Trends

For various reasons, many communities where excision was once an aspect of elaborate rites of passage celebrations with minimum age requirements now excise children who are too young to comprehend the ritual implications of the experience. A corollary of this development is that some persons undergo the operation independent of accompanying ceremonies. In contradistinction to the evolving tendency to cut the genitalia without performing complementary ritual ceremonies, a few communities are embracing alternative rites that replace physical cutting with symbolic enactments. Here initiation modules only entail health education, transmission of traditional knowledge, and festivity.

Patterns of change are also manifesting in more decidedly oppositional guises. Often, fierce opposition is a catalyst for other forms of transformation. Accordingly, it is not unusual to find the circumcision of the under-age and/or unceremonious cutting as forms of resistance to intense expressions of ant circumcision impulses. These conflicts mutually reinforce each other.

An abiding bone of contention in the controversy about excision is the question of its health effects. Increasingly, the veracity of extant claims about health hazards and the premium that is placed on it as an arsenal for the anti-circumcision campaign, are being attacked. Searching analyses of available research suggest that advocates of abolition are quicker abstractly to chronicle an array of hazards than they are to produce objective evidence to back up their claims about the severity and frequency of health complications. Where these claims cannot be substantiated empirically, they operate as mere propaganda that remain unrepresentative of the lived experiences of circumcised persons. Although existing data are deficient, there is sufficient evidence to demonstrate that the health complications that are attributable to excision vary with the extent and circumstances of the surgery. The health hazards of the operation typically are compounded by the crude circumstances under which it usually occurs, including the lack of anesthesia and the use of unsterile instruments.

Drastic forms of excision such as clitordectomy are associated with an increased risk of bleeding and infection; the complications of infibulation include serious bleeding, infections, urinary problems, infertility, labor and delivery difficulties, and adhesions and obstructions. There is no objective evidence that directly links excision with mortality. The World Health Organization categorizes a range of possible negative health consequences as follows: short-term complications which include pain, injury to adjacent tissues, potentially fatal hemorrhage and shock, urinary retention, and acute and chronic infections; long-term complications that range from difficulty in passing urine, urinary tract infections, pelvic infections, infertility, keloid scars, abscesses and cysts, to menstrual difficulties, dyspareunia and sexual dysfunctions, and problems in pregnancy and childbirth as well as sexual, mental, and social consequences.

This list is more concise and less exaggerated than the inventories of deleterious sequalae in other literature; nevertheless, it is subject to caution as it derives from cross-sectional studies that are not always able to establish direct causation between the operation and the putative complication. This list is also comparable to other studies in the sense that it offers little guidance for inferring the rates of complications. Recent systematic reviews of relevant materials show that consistent and conclusive evidence of far-reaching complications are rare. These observations call for the qualification of the claims at the heart of the anticircumcision campaign strategy. Notwithstanding the observations, the anti-circumcision alliance has done a remarkable job of mobilizing international consensus against the practice by emphasizing its harmful effects.

3.1 Eradication

Systematic efforts to abolish excision date back to the colonial era. In 1946, the British colonial administration in Sudan amended its Penal Code to make illegal all forms of genital surgeries, except sunna. In Kenya, interference by missionaries condemned the practice to secrecy; as a clandestine custom, it was particularly difficult to assess the incidence of casualties. In material respects, the intervention also politicized the significance of the operation as some began to appropriate it as a symbol of nationalism. According to Kenyatta (1938), the controversy came to a head in 1929–30 when families who interpreted the colonist measures as an affront to their freedom, social customs, and cultural beliefs hastened to circumcise their daughters, even at the hands of unskilled persons with inevitable tragic consequences.

The backlash recurred in 1989 when the incumbent President of Kenya, Arap Moi, denounced the custom and scores of women and girls volunteered for the procedure in protest of the official sanction. More recently, some grassroots communities are reinforcing, instead of resisting heightening global pressure against circumcision. To this end, several villages have adopted renunciation oaths and declarations that they complement with active learning and socioeconomic empowerment programs. Some eradication strategies train former excisors in grassroots management skills and facilitate their involvement in business enterprises. In lieu of material benefits, certain competing models—especially those that reconfigure the rite to eliminate the ritual of cutting—incorporate creative ways of enlisting the support of traditional excisors.

Several sovereign powers have prescribed an assortment of steps to stem excision. These range from economic sanctions and extradition to prosecution and punishment. In 1991, France became the first country to establish that the threat of ‘genital mutilation’ is sufficient grounds to grant women refugee status. Subsequently, Canada pioneered guidelines expanding the basis of refugee claims to include gender-related persecution which was construed to encompass circumcision. More recently in the United States, a few African women have succeeded in obtaining political asylum or staying deportation by conceptualizing circumcision as persecution.

A series of human rights instruments and provisions can also be read as prohibiting excision. These range from regulations concerning equal protection and nondiscrimination to those pertaining to the rights of children, the right of sexual and corporal integrity, the right against torture, the right to life, and the right to health. The World Health Organization officially condemned surgical alterations of female genitalia in 1982. The World Medical Association, the International Federation of Gynaecology and Obstetrics, and the Population Fund issued warnings about the risks of the practice and oppose the participation of health professionals in it. In 1990, the Committee responsible for the implementation of the Convention for the Elimination of Discrimination against Women recommended the eradication of the practice.

Although a few African countries have instituted various initiatives to address excision, it appears that the force of culture and the poverty of resources inhibit meaningful implementation of these initiatives. A wide range of official declarations against excision have been made in Benin, Nigeria, Ghana, Burkina Faso, and Senegal. Some European countries have also promulgated relevant laws and policies. Several interventions promote prevention through information, education, and communication campaigns. However, the predominant trend proscribes the practice as a crime that is subject to prosecution. As of the summer of 1994, France was the only country in which the practice of circumcision has actually resulted in criminal trials. In 1982, the Royal College of Obstetricians and Gynecologists found that excision was a very infrequent occurrence in Britain. By 1985 however, a scare of waves of occurrences prompted the promulgation of the British Prohibition of Circumcision Act. Section 1 of the Act makes it an ‘offense for any person (a) to excise, infibulate or otherwise mutilate the whole or any part of the labia majora or labia minora or clitoris of another person; or (b) to aid, abet, counsel or procure the performance by another person of any of those acts on that other person’s own body.’ Section 2 of the Act indicates that genital surgeries are not absolutely prohibited; its precise wording seems to accommodate exceptions under certain circumstances. This section provides that ‘Subsection 1(a) of Section 1 shall not render unlawful the performance of a surgical operation if that operation (a) is necessary for the physical or mental health of the person on whom it is performed and is performed by a registered medical practitioner.’ This provision allows the continuation of ‘trimming’ surgeries that typically are performed on women who are dissatisfied and psychologically disturbed by the shape or size of their external genitalia. Plausibly, the mental health exemption can be construed to support psychologically-grounded claims for circumcision. However, section 2 (2) of the Act precludes the consideration of psychological effects induced by any belief ‘that the operation is required as a matter of custom or ritual.’

In 1996, the US Congress made the excision of a person who has not attained the age of 18 a felony punishable by up to five years imprisonment. This statute equally exempts a surgical procedure performed by a licensed medical practitioner, which is either necessary for the health of the woman on whom it is performed, or is performed prenatally or postnatally on a woman. The US Congress further authorized the imposition of economic sanctions against any countries that have a cultural custom of female circumcision and have not implemented educational programs to counteract the practice. Resorting to this course of action as an antidote to circumcision is not without limitations. Withholding or conditioning aid as a mechanism for controlling the practice subordinates humanitarian considerations to political expedience. While there obviously are no simple solutions, it is important to recognize that when deeply embedded cultural attitudes are reinforced by complex economic, social, and political variables, a more nuanced strategy may be more effective than essentially top-down or carrot-and-stick approaches.

3.2 Medicalization

Empirical evidence of the range and frequency of adverse health outcomes posit a strong correlation between the probability of harm and the degree of cutting, the nonhygienic and anesthetic conditions under which it is performed, and the limited skills of the excisor. Drawing on these findings, some authorities recommend a spectrum of medical interventions as a way of containing potential harm. In one initiative, nurses dispense prophylactic antibiotics, anti-tetanus injections, and sterile razors to girls who are later cut by traditional circumcisors. In another model, traditional birth attendants are trained in septic and precautionary procedures for genital cutting. In urban parts of Sudan and in Egypt, the governments have attempted to curtail the adverse health consequences that can be traced to excision by clinicalizing mild forms of the procedure. In the Netherlands, a Welfare, Health and Cultural Ministry report and officials at the Harborview Medical Center in Seattle in the US recommended a similar course of action.

Apparently some African immigrants in Holland circumcised themselves under circumstances that compound the potential harms of the procedure. Their dilemma arose partly because, while they could not afford to be alienated for failure to comply with the cultural mandate for circumcision, the Dutch medical and social workers denied them assistance in executing the operation. To address the needs of these women, the Ministry, on the basis of the findings of a study it sponsored among 500 Somali refugee women, recommended a distinction between mutilating or tissue-impairing circumcision and nonmutilating ritual incisions. The report further argued for official stipulation of conditions under which doctors might be allowed to perform simple incisions or ritual perforations of the clitoral covering as an alternative to infibulation. The report drew a storm of protests and eventually was superseded in 1992.

In 1996, a similar controversy erupted in Seattle, Washington, when in the interest of some Somalian immigrants, pediatricians at Harborview Medical Center took under advisement the possibility of performing ‘symbolic blood-letting’ procedures on girls. The proposed procedure would only involve a negligible nicking of the prepuce far less invasive than what is allowed in the circumcision of infant males. Beseiged by outraged opponents, Harborview decided to abandon the prospective accommodation.

The Dutch and Seattle experiences illustrate the extent to which sworn opponents of the practice favor prohibition and are vehemently opposed to medicalizing any variant of the practice—even as an interim measure to arrest potentially dire consequences.

One reason proffered for this position is that the surgical compromise ultimately signals complicity in patriarchal control and diminution of the right of women to sexual and bodily integrity. Some ridicule operations performed under medical conditions and/or supervision as an empty caricature devoid of traditional connotations. Others who envisage a scenario where traditional midwives are displaced by forum change seek to enhance their fundamental opposition to the practice by coupling it with an ancillary aversion to the implicit loss of income for the midwives. Another concern is that medicalization may unduly burden and deplete public funds which could be deployed for less controversial purposes. It is also contended that the compromise creates a slippery slope that can be abused to camouflage severe forms of the operation.

Whatever the validity of these concerns, it is worth ruminating over the merits of changing the forum and form of the practice. The options may be problematic, but as already suggested, there are no exact solutions. Criminalization, which is overwhelmingly championed by the anticircumcision coalition, is not a panacea. Indeed, where not being excized is perceived as a transgression of social mores, attempting an undifferentiated assault may jeopardize the prospects for enduring reform. The rhetoric of the opposition is premised largely on claims about the health hazards of excision. However, a recent examination of how much available research supports widely publicized allegations about the prevalence and harmful effects of female genital surgeries found that most of what are purported to be universal ‘facts’ vis-a-vis the deleterious consequences are drawn from studies of the Sudan where most women are infibulated. The review confirmed that obtaining irrefutable epidemiological data is limited by logistical and ethical constraints involved in monitoring over time the experience of individuals who undergo the surgeries.

The fact that adverse complications are exacerbated by the poor skills, anatomical knowledge, sanitary conditions, and surgical equipment that characterize excision in traditional settings reinforces arguments for medicalization. By the same token, instituting a change of form such as symbolic pricking is inconsequential from a health standpoint. Without a probable risk of harm, it is difficult to make a compelling case against the accommodation of consensual genital marking. In this light, medicalization reconciles the need to protect women with a respect for embodied sociocultural identities. Some would even argue that the virtue of tolerance and the principle of self-determination allow accommodation of more extensive genital alterations, as long as the procedure is demonstrably benign. Given the current wave of anticircumcision sentiments, this view is subject to dispute and far from endorsement. Nevertheless, it raises issues that deserve serious attention.

3.3 Education

Several authorities hail education as the single most important factor in combating the practice. For one, law alone seldom changes behavior. Effective legal engineering can hardly occur without favorable public disposition, which in turn can be stimulated by fostering meaningful interactions between legal and educational strategies. In this vein, it is noteworthy that gains achieved through the medium of education are often contingent and enhanced by concurrent poverty alleviation. The emphasis on education and connection with poverty, however, can only go so far. The substantial prevalence rate of the genital operations among very educated and privileged women in many ethnic groups suggests that advances in literacy and socioeconomic status do not necessarily decrease allegiance to circumcision. Undoubtedly, good education is an effective antidote for challenging erroneous beliefs. However, many women undergo circumcision on the bases of rationales that cannot be readily refuted by objective evidence. Ritual thought and action belong to specific symbolic frames of reference and are best understood within the totality of their natural context. Attempting to falsify indigenous explanations of circumcision by regarding them as assertions of facts that can be disconfirmed through formally logical discursive categories obscure valid psychosocial processes.

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