Female genital mutilation

Female genital mutilation (FGM), also known as female genital cutting and female circumcision, is the ritual removal of some or all of the external female genitalia. Typically carried out by a traditional circumciser using a blade or razor (with or without anaesthesia), FGM is concentrated in 27 African countries, Yemen and Iraqi Kurdistan, and found elsewhere in Asia, the Middle East, and among diaspora communities around the world.For the circumcisers, blade/razor, anaesthesia, UNICEF 2013, pp. 2, 44–46; for the 29 countries, pp. 26–27. The age at which it is conducted varies from days after birth to puberty. In half the countries for which national figures are available, most girls are cut before the age of five.
The procedures differ according to the ethnic group. They include removal of the clitoral hood and clitoral glans, removal of the inner labia, and in the most severe form (known as infibulation) removal of the inner and outer labia and closure of the vulva. In this last procedure, a small hole is left for the passage of urine and menstrual fluid; the vagina is opened for intercourse and opened further for childbirth. Health effects depend on the procedure, but can include recurrent infections, chronic pain, cysts, an inability to get pregnant, complications during childbirth, and fatal bleeding.Jasmine Abdulcadira, et al, "Care of women with female genital mutilation/cutting", Swiss Medical Weekly, 6(14), January 2011. There are no known health benefits."Female genital mutilation", New York: World Health Organization, February 2014.
The practice is rooted in gender inequality, attempts to control women's sexuality, and ideas about purity, modesty and aesthetics. It is usually initiated and carried out by women, who see it as a source of honour and fear that failing to have their daughters and granddaughters cut will expose the girls to social exclusion. Over 130 million women and girls have experienced FGM in the 29 countries in which it is concentrated.
The United Nations Population Fund estimates that 20 percent of affected women have been infibulated, a practice found largely in northeast Africa, particularly Djibouti, Eritrea, Somalia and northern Sudan.
FGM has been outlawed or restricted in most of the countries in which it occurs, but the laws are poorly enforced.For countries in which it is outlawed or restricted, UNICEF 2013, p. 8; for enforcement, UNFPA–UNICEF 2012, p. 48. There have been international efforts since the 1970s to persuade practitioners to abandon it, and in 2012 the United Nations General Assembly, recognizing FGM as a human-rights violation, voted unanimously to intensify those efforts. The opposition is not without its critics, particularly among anthropologists. Eric Silverman writes that FGM has become one of anthropology's central moral topics, raising difficult questions about cultural relativism, tolerance and the universality of human rights.Eric K. Silverman, "Anthropology and Circumcision", Annual Review of Anthropology, 33, 2004 (pp. 419–445), pp. 420, 427.
==Terminology==
===English===
Until the 1980s FGM was widely known as female circumcision, which implied an equivalence in severity with male circumcision.Martha Nussbaum, Sex and Social Justice, New York: Oxford University Press, 1999, p. 119. The Kenya Missionary Council began referring to it as the sexual mutilation of women in 1929, following the lead of Marion Scott Stevenson, a Church of Scotland missionary.James Karanja, The Missionary Movement in Colonial Kenya: The Foundation of Africa Inland Church, Göttingen: Cuvillier Verlag, 2009, p. 93, n. 631. References to it as mutilation increased throughout the 1970s."Eliminating Female genital mutilation: An Interagency Statement", New York: World Health Organization, 2008 (hereafter WHO 2008), p. 22. Anthropologist Rose Oldfield Hayes called it female genital mutilation in 1975 in the title of a paper, and in 1979 Austrian-American researcher Fran Hosken called it mutilation in her influential The Hosken Report: Genital and Sexual Mutilation of Females.Rose Oldfield Hayes, "Female Genital Mutilation, Fertility Control, Women's Roles, and the Patrilineage in Modern Sudan: A Functional Analysis", American Ethnologist 2(4), November 1975, pp. 617–633.
Fran Hosken, The Hosken Report: Genital and Sexual Mutilation of Females, Lexington: Women's International Network, 1994 [1979].
Claire C. Robertson, "Getting beyond the Ew! Factor: Rethinking U.S. Approaches to African Female Genital Cutting," in Stanlie M. James and Claire C. Robertson (eds.), Genital Cutting and Transnational Sisterhood, Urbana: University of Illinois Press, 2002 (pp. 54–86), p. 60: "The Hosken Report is the single most influential document responsible for raising consciousness of FGC."
The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children and the World Health Organization (WHO) began referring to it as female genital mutilation in 1990 and 1991 respectively.UNICEF 2013, pp. 6–7. In April 1997 the WHO, United Nations Children's Fund (UNICEF) and United Nations Population Fund (UNFPA) issued a joint statement using that term. Other terms include female genital cutting (FGC) and female genital mutilation/cutting (FGM/C), preferred by those who work with practitioners.WHO 2008, pp. 4, 22.
===Local terms===
The many variants of FGM are reflected in dozens of local terms in countries where it is common. These often refer to purification. A common Arabic term for purification has the root t-h-r, used for male and female circumcision (tahur and tahara).Fadwa El Guindi, "Had This Been Your Face, Would You Leave It as Is?" in Rogaia Mustafa Abusharaf (ed.), Female Circumcision: Multicultural Perspectives, Philadelphia: University of Pennsylvania Press, 2007, p. 30. In Islamic texts the practice is referred to as khafḍ ()"Khafḍ", Encyclopædia Britannica. or khifaḍ ().Clarence-Smith, William G. "Islam and Female Genital Cutting in Southeast Asia: The Weight of the Past," Finnish Journal of Ethnicity and Migration, 3(2), 2008, p. 14. In the Bambara language, spoken mostly in Mali, FGM is known as bolokoli ("washing your hands") and in the Igbo language in eastern Nigeria as isa aru or iwu aru ("having your bath" – as in "a young woman must 'have her bath' before she has a baby").Chantal Zabus, "The Excised Body in African Texts and Contexts," in Merete Falck Borch (ed.), Bodies and Voices: The Force-field of Representation and Discourse in Colonial and Postcolonial Studies, New York: Rodopi, 2008, p. 47.
For "a young woman must 'have her bath' before she has a baby," Chantal Zabus, "'Writing with an Accent': From Early Decolonization to Contemporary Gender Issues in the African Novel in French, English, and Arabic," in Simona Bertacco (ed.), Language and Translation in Postcolonial Literatures, New York: Routledge, 2013, p. 40.
Sunna circumcision usually refers to clitoridectomy], but is also used for the more severe forms; sunna means "path or way" in Arabic and refers to the tradition of Muhammad, although none of the procedures are required within Islam.Ibrahim Lethome Asmani, Maryam Sheikh Abdi, "De-linking Female Genital Mutilation/Cutting from Islam", USAID/UNFPA, 2008, p. 3.
That sunna can refer to more severe forms, Ellen Gruenbaum, The Female Circumcision Controversy: An Anthropological Perspective, Philadelphia: University of Pennsylvania Press, 2001, p. 2. The term infibulation derives from fibula, Latin for clasp; the Ancient Romans reportedly fastened clasps through the foreskins or labia of slaves to prevent sexual intercourse.Leonard J. Kouba, Judith Muasher, "Female Circumcision in Africa: An Overview", African Studies Review, 28(1), March 1985 (pp. 95–110), pp. 96–97. The surgical infibulation of women came to be known as pharaonic circumcision in Sudan, but as Sudanese circumcision in Egypt. In Somalia it is known simply as qodob ("to sew up").Raqiya D. Abdalla, My Grandmother Called it the Three Feminine Sorrows': The Struggle of Women Against Female Circumcision in Somalia," in Abusharaf 2007, p. 190.
==Circumcisers, methods==
The procedures are generally performed by a traditional circumciser in the girls' homes, with or without anaesthesia. The circumciser is usually an older woman, but in communities where the male barber has assumed the role of health worker he will perform FGM too.UNICEF 2013, pp. 42–44 and Table 5, p. 181 (for cutters), p. 46 (for home and anaesthesia). Health professionals are often involved in Egypt, Sudan and Kenya; according to a 2008 survey in Egypt, 77 percent of FGM procedures there were performed by medical professionals, often physicians.UNICEF 2013, pp. 43–45.
When traditional circumcisers are involved, non-sterile cutting devices are likely to be used, including knives, razors, scissors, glass, sharpened rocks and fingernails.Elizabeth Kelly, Paula J. Adams Hillard, "Female genital mutilation", Current Opinion in Obstetrics & Gynecology, 17(5), October 2005 (pp. 490–494), p. 491. A nurse in Uganda, quoted in 2007 in The Lancet, said that a circumciser would use one knife to cut up to 30 girls at a time.Wairagala Wakabi, "Africa battles to make female genital mutilation history", The Lancet, 369 (9567), 31 March 2007, pp. 1069–1070. Depending on the involvement of healthcare professionals, the procedures may include a local or general anaesthetic, or neither. Women in Egypt reported in 1995 that a local anaesthetic had been used on their daughters in 60 percent of cases, a general in 13 percent and neither in 25 percent.UNICEF 2013, p. 46 (two percent were missing/don't know).
==Classification==
===Typologies===
The WHO, UNICEF and UNFPA issued a joint statement in April 1997 defining FGM as "all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or other non-therapeutic reasons."WHO 2008, p. 4.
The procedures vary considerably according to ethnicity and individual practitioners. During a 1998 survey in Niger, women responded with over 50 different terms when asked what was done to them.UNICEF 2013, p. 48. Translation problems are compounded by the women's confusion over which type of FGM they experienced, or even whether they experienced it. Several studies suggest survey responses are unreliable. A 2003 study in Ghana found that in 1995 four percent said they had not undergone FGM, but in 2000 said they had, while 11 percent switched in the other direction. In Tanzania in 2005, 66 percent reported FGM, but a medical exam found that 73 percent had undergone it.P. Stanley Yoder, Shanxiao Wang, Elise Johansen, "Estimates of Female Genital Mutilation/Cutting in 27 African Countries and Yemen", Studies in Family Planning, 44(2), June 2013 (pp. 189–204), p. 190. 
Elizabeth F. Jackson, et al., "Inconsistent reporting of female genital cutting status in northern Ghana: Explanatory factors and analytical consequences," Studies in Family Planning, 34(3), 2003, pp. 200–210. 
Elise Klouman, Rachel Manongi, Knut-Inge Klepp, "Self-reported and observed female genital cutting in rural Tanzania: Associated demographic factors, HIV and sexually transmitted infections", Tropical Medicine and International Health 10(1), 2005, pp. 105–115. 
In Sudan in 2006, a significant percentage of infibulated women and girls reported a less severe type. See Susan Elmusharaf, Nagla Elhadi, Lars Almroth, "Reliability of self reported form of female genital mutilation and WHO classification: cross sectional study", British Medical Journal, 332(7559), 27 June 2006. 
Standard questionnaires ask women whether they have undergone the following: (1) cut, no flesh removed (pricking or symbolic circumcision); (2) cut, some flesh removed; (3) sewn closed; and (4) type not determined/unsure/doesn't know.UNICEF 2013, p. 48: "These categories do not fully match the WHO typology. Cut, no flesh removed describes a practice known as nicking or pricking, which currently is categorized as Type IV. Cut, some flesh removed corresponds to Type I (clitoridectomy) and Type II (excision) combined. And sewn closed corresponds to Type III, infibulation." The most common procedures fall within the "cut, some flesh removed" category, and involve complete or partial removal of the clitoral glans.UNICEF 2013, p. 47, Table 5.2; Yoder, Wang and Johansen, 2013, p. 189.
===WHO Types I–II===
The WHO has created a more detailed typology, Types I–III, based on how much tissue is removed; Type III is "sewn closed." Type IV describes symbolic circumcision and miscellaneous procedures.WHO 2014; WHO 2008, p. 4, and Annex 2, p. 24, for Types I–IV; Annex 2, pp. 23–28, for a more detailed discussion.
Type I is subdivided into Ia, removal of the clitoral hood (rarely performed alone),WHO 2008, p. 25: "[There is a] common tendency to describe Type I as removal of the prepuce, whereas this has not been documented as a traditional form of female genital mutilation. However, in some countries, medicalized female genital mutilation can include removal of the prepuce only (Type Ia) (Thabet and Thabet, 2003), but this form appears to be relatively rare (Satti et al, 2006). Almost all known forms of female genital mutilation that remove tissue from the clitoris also cut all or part of the clitoral glans itself."
Also see Nahid Toubia, "Female Circumcision as a Public Health Issue", The New England Journal of Medicine, 331(11), 1994, pp. 712–716. 
Carol R. Horowitz, J. Carey Jackson, Mamae Teklemariam, "Female Circumcision" (letters), The New England Journal of Medicine, 332, 19 January 1995, pp. 188–190; Toubia's reply. and the more common Ib (clitoridectomy), the complete or partial removal of the clitoral glans and clitoral hood.WHO 2014; WHO 2008, p. 4. (When discussing FGM, the WHO uses clitoris to refer to the clitoral glans, the visible tip of the clitoris.)WHO 2008, Annex 2, p. 23. Susan Izett and Nahid Toubia write: "[T]he clitoris is held between the thumb and index finger, pulled out and amputated with one stroke of a sharp object."Susan Izett, Nahid Toubia, Female Genital Mutilation: An Overview, World Health Organization, 1998.
Type II (excision) is the complete or partial removal of the inner labia, with or without removal of the clitoral glans and outer labia. Type IIa is removal of the inner labia; IIb, removal of the clitoral glans and inner labia; and IIc, removal of the clitoral glans, inner and outer labia. Excision in French can refer to any form of FGM.WHO 2014.
===Type III===
Type III (infibulation or pharaonic circumcision), the "sewn closed" category, involves the removal of the external genitalia and fusion of the wound. The inner and/or outer labia are cut away, with or without removal of the clitoral glans. Type IIIa is the removal and closure of the inner labia and IIIb the outer labia.WHO 2014: "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 IIIa, removal and apposition of the labia minora; Type IIIb, removal and apposition of the labia majora." The practice is found largely in Djibouti, Eritrea, Ethiopia, Somalia and Sudan (though not South Sudan) in northeast Africa. Estimates of numbers vary: according to one in 2008, over eight million women in Africa have experienced it. According to UNFPA in 2010, 20 percent of women with FGM have been infibulated."Frequently Asked Questions on Female Genital Mutilation/Cutting", UNFPA, April 2010: "Types I and II are the most common, with variation among countries. Type III, infibulation, constitutes about 20 percent of all affected women and is most likely in Somalia, northern Sudan and Djibouti."
Comfort Momoh, a specialist midwife, writes of Type III: "[E]lderly women, relatives and friends secure the girl in the lithotomy position. A deep incision is made rapidly on either side from the root of the clitoris to the fourchette, and a single cut of the razor excises the clitoris and both the labia majora and labia minora."Comfort Momoh, "Female genital mutilation" in Comfort Momoh (ed.), Female Genital Mutilation, Oxford: Radcliffe Publishing, 2005, p. 7; also see Edna Adan Ismail, "Female genital mutilation survey in Somaliland", Edna Adan Maternity and Teaching Hospital, 2009, pp. 12–14. In Somalia the clitoral glans is removed and shown to the girl's senior female relatives, who decide whether enough has been amputated. After this the labia are removed.Ismail 2009, p. 12; also see Abusharaf 2007, p. 190.
A single hole of 2–3 mm is left for the passage of urine and menstrual fluid by inserting something, such as a twig, into the wound.Abdulcadira et al 2011: "In the case of infibulation, the urethral orifice and part of the vaginal opening are covered by the scar. In a virgin infibulated woman the small opening left for the menstrual fluid and the urine is not wider than 2–3 mm; in sexually active women and after the delivery the vaginal opening is wider but the urethral orifice is often still covered by the scar."
For a twig, Momoh 2005, p. 7. The vulva is closed with surgical thread, agave or acacia thorns, or covered with a poultice such as raw egg, herbs and sugar.Kelly and Hillard 2005, p. 491; for the poultice, Ismail 2009, p. 14. The parts that have been removed might be placed in a pouch for the girl to wear.El Guindi 2007, p. 43. To help the tissue bond, the girl's legs are tied together, often from hip to ankle, for anything up to six weeks; the bindings are usually loosened after a week and may be removed after two.Kelly and Hillard 2005, p. 491 (Kelly and Hillard say the girls are tied for 2–6 weeks); Momoh 2005, pp. 6–7; for progressive loosening of the binding, Ismail 2009, p. 14. Momoh writes:
[The entrance to the vagina] is obliterated by a drum of skin extending across the orifice except for a small hole. Circumstances at the time may vary; the girl may struggle ferociously, in which case the incisions may become uncontrolled and haphazard. The girl may be pinned down so firmly that bones may fracture.
If the remaining hole is too large in the view of the girl's family, the procedure is repeated.
Abdalla 2007, p. 190. The vagina is opened for sexual intercourse, for the first time either by a midwife with a knife or by the woman's husband with his penis. In some areas, including Somaliland, female relatives of the bride and groom might watch the opening of the vagina to check that the girl is a virgin.Abdalla 2007, pp. 191, 198; for the relatives, Ismail 2009, p. 14. Psychologist Hanny Lightfoot-Klein interviewed hundreds of women and men in Sudan in the 1980s about sexual intercourse with Type III:
The penetration of the bride's infibulation takes anywhere from 3 or 4 days to several months. Some men are unable to penetrate their wives at all (in my study over 15%), and the task is often accomplished by a midwife under conditions of great secrecy, since this reflects negatively on the man's potency. Some who are unable to penetrate their wives manage to get them pregnant in spite of the infibulation, and the woman's vaginal passage is then cut open to allow birth to take place. ... Those men who do manage to penetrate their wives do so often, or perhaps always, with the help of the "little knife." This creates a tear which they gradually rip more and more until the opening is sufficient to admit the penis.Hanny Lightfoot-Klein, "The Sexual Experience and Marital Adjustment of Genitally Circumcised and Infibulated Females in The Sudan", The Journal of Sex Research, 26(3), 1989 (pp. 375–392), p. 380.
Also see El Dareer 1982, pp. 42–49; Hanny Lightfoot-Klein, Prisoners of Ritual: An Odyssey Into Female Genital Circumcision in Africa, New York: Routledge, 1989.
The woman is opened further for childbirth and closed afterwards, a process known as defibulation (or deinfibulation) and reinfibulation. Reinfibulation can involve cutting the vagina again to restore the pinhole size of the first infibulation. This might be performed before marriage, and after childbirth, divorce and widowhood.Kelly and Hillard 2005, p. 491: "Women commonly undergo reinfibulation after a vaginal delivery. In addition to reinfibulation, many women in Sudan undergo a second type of re-suturing called El-Adel, which is performed to recreate the size of the vaginal orifice to be similar to the size created at the time of primary infibulation. Two small cuts are made around the vaginal orifice to expose new tissues to suture, and then sutures are placed to tighten the vaginal orifice and perineum. This procedure, also called re-circumcision, is primarily performed after vaginal delivery, but can also be performed before marriage, after cesarean section, after divorce, and sometimes even in elderly women as a preparation before death."
Asma El Dareer, Woman, Why Do You Weep: Circumcision and its Consequences, London: Zed Press, 1982, pp. 56–64.
Also see Rebecca J. Cooke, Bernard M. Dickens, "Special commentary on the issue of reinfibulation", International Journal of Gynaecology and Obstetrics, 109(2), May 2010, pp. 97–99. 
Gamal I. Serour, "The issue of reinfibulation", International Journal of Gynaecology and Obstetrics, 109(2), May 2010, pp. 93–96. 
Olukunmi O. Balogun, et al, "Interventions for improving outcomes for pregnant women who have experienced genital cutting", Cochrane Database of Systematic Reviews, 2, 2013. 
===Type IV===
The WHO defines Type IV as "[a]ll other harmful procedures to the female genitalia for non-medical purposes," including pricking, piercing, incising, scraping and cauterization. It includes nicking of the clitoris (symbolic circumcision), burning or scarring the genitals, and introducing substances into the vagina to tighten it.WHO 2008, p. 24; UNICEF 2013, p. 7. Labia stretching is also categorized as Type IV.WHO 2008, p. 27. Common in southern and eastern Africa, the practice is supposed to enhance sexual pleasure for the man and add to the sense of a woman as a closed space. From the age of eight, girls are encouraged to stretch their inner labia using sticks and massage. Girls in Uganda are told they may have difficulty giving birth without stretched labia.For the countries in which labia stretching is found (Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Tanzania, Uganda and Zimbabwe), Nkiru Nzegwu, "'Osunality' (or African eroticism)" in Sylvia Tamale (ed.), African Sexualities: A Reader, Cape Town: Fahamu/Pambazuka, 2011, p. 262.
For the rest, Brigitte Bagnol and Esmeralda Mariano, "Politics of Naming Sexual Practices," in Tamale 2011, pp. 272–276 (p. 272 for Uganda).
"Female Genital Mutilation: A Teachers' Guide", World Health Organization, 2005, p. 31: "In some areas (e.g. parts of Congo and mainland Tanzania), FGM entails the pulling of the labia minora and/or clitoris over a period of about 2 to 3 weeks. The procedure is initiated by an old woman designated for this task, who puts sticks of a special type in place to hold the stretched genital parts so that they do not revert back to their original size. The girl is instructed to pull her genitalia every day, to stretch them further, and to put additional sticks in to hold the stretched parts from time to time. This pulling procedure is repeated daily for a period of about two weeks, and usually no more than four sticks are used to hold the stretched parts, as further pulling and stretching would make the genital parts unacceptably long."
A definition of FGM from the WHO in 1995 included gishiri cutting and angurya cutting, found in Nigeria and Niger. These were removed from the WHO's 2008 definition because of insufficient information about prevalence and consequences. Gishiri cutting involves cutting the vagina's front or back wall with a blade or penknife, performed in response to infertility, obstructed labour and several other conditions. Over 30 percent of women with gishiri cuts in a study by Nigerian physician Mairo Usman Mandara had vesicovaginal fistulae. Angurya cutting is excision of the hymen, usually performed seven days after birth.Mairo Usman Mandara, "Female genital cutting in Nigeria: View of Nigerian Doctors on the Medicalization Debate," in Bettina Shell-Duncan and Ylva Hernlund (eds.), Female "Circumcision" in Africa: Culture Controversy and Change, Boulder: Lynne Rienner Publishers, 2000 (pp. 253–282), pp. 98, 100; for fistulae, p. 102.
Mairo Usman Mandara, "Female genital mutilation in Nigeria", International Journal of Gynecology & Obstetrics, 84(3), pp. 291–298. 
==Complications==
===Short term and late===
FGM harms women's physical and emotional health throughout their lives.Rigmor C. Berg, et al., "Effects of female genital cutting on physical health outcomes: a systematic review and meta-analysis", BMJ Open, 4(11), 2014: e006316. Dan Reisel, Sarah M. Creighton, "Long term health consequences of Female Genital Mutilation (FGM)", Maturitas, 80(1), January 2015 (pp. 48–51), p. 49. It has no known health benefits. The short-term and late complications depend on the type of FGM, whether the practitioner had medical training, and whether she used antibiotics and unsterilized or surgical single-use instruments. In the case of Type III, other factors include how small a hole was left for the passage of urine and menstrual blood, whether surgical thread was used instead of agave or acacia thorns, and whether the procedure was performed more than once (for example, to close an opening regarded as too wide or re-open one too small).
Common short-term complications include swelling, excessive bleeding, pain, urine retention and healing problems/wound infection. A 2015 systematic review of 56 studies that recorded immediate complications suggested that each of these occurred in more than one in ten girls and women undergoing any form of FGM, including symbolic nicking of the clitoris (Type IV), although the risks increased with Type III. The review also suggested that there was under-reporting.Rigmor C. Berg, Vigdis Underland, Immediate health consequences of female genital mutilation/cutting (FGM/C), Kunnskapssenteret (Norwegian Knowledge Centre for the Health Services), systematic review no. 8, 2014, pp. 4–5 (full text). ISBN 978-82-8121-856-7 Other short-term complications include fatal bleeding, anaemia, urinary infection, septicaemia, tetanus, gangrene, necrotizing fasciitis (flesh-eating disease) and endometritis.Christos Iavazzo, Thalia A. Sardi, Ioannis D. Gkegkes, "Female genital mutilation and infections: a systematic review of the clinical evidence", Archives of Gynecology and Obstetrics, 287(6), June 2013, pp. 1137–1149. It is not known how many girls and women die as a result of the practice, because complications may not be recognized or reported.UNICEF 2005, p. 16.Reisel and Creighton 2015, p. 50. The practitioners' use of shared instruments is thought to aid the transmission of hepatitis B, hepatitis C and HIV, although no epidemiological studies have shown this.
Late complications vary depending on the type of FGM. They include the formation of scars and keloids that lead to strictures and obstruction, epidermoid cysts that may become infected, and neuroma formation (growth of nerve tissue) involving nerves that supplied the clitoris.Amish J. Dave, Aisha Sethi, Aldo Morrone, "Female Genital Mutilation: What Every American Dermatologist Needs to Know", Dermatologic Clinics, 29(1), January 2011, pp. 103–109. An infibulated girl may be left with an opening as small as 2–3 mm, which can cause prolonged, drop-by-drop urination, pain while urinating, and a feeling of needing to urinate all the time. Urine may collect underneath the scar, leaving the area under the skin constantly wet, which can lead to infection and the formation of small stones. The opening is larger in women who are sexually active or have given birth by vaginal delivery, but the urethra opening may still be obstructed by scar tissue.Vesicovaginal or rectovaginal fistulae can develop (holes that allow urine or faeces to seep into the vagina).Hamid Rushwan, "Female genital mutilation: A tragedy for women's reproductive health", African Journal of Urology, 19(3), September 2013, pp. 130–133. This and other damage to the urethra and bladder can lead to infections and incontinence, pain during sexual intercourse and infertility.Kelly and Hillard 2005, pp. 491–492
Painful periods are common because of the obstruction to the menstrual flow, and blood can stagnate in the vagina and uterus. Complete obstruction of the vagina can result in hematocolpos and hematometra (where the vagina and uterus fill with menstrual blood). The swelling of the abdomen that results from the collection of fluid, together with the lack of menstruation, can lead to suspicion of pregnancy. Physician Asma El Dareer reported in 1979 that a young girl in Sudan with this condition was killed by her family.El Dareer 1982, p. 37. Also see Asma El Dareer, "Preliminary report on a study on prevalence and epidemiology of female circumcision in Sudan today," WHO seminar, Khartoum, 10–15 February 1979; Asma el Dareer, "Female circumcision and its consequences for mother and child," Yaounde, 12–15 December 1979, cited in Rushwan 2013.
===Pregnancy, childbirth===
FGM may place women at higher risk of problems during pregnancy and childbirth, which are more common with the more extensive FGM procedures. Infibulated women may try to make childbirth easier by eating less during pregnancy to reduce the baby's size.Rashid and Rashid 2007, p. 99. In women with vesicovaginal or rectovaginal fistulae, it is difficult to obtain clear urine samples as part of prenatal care, making the diagnosis of conditions such as pre-eclampsia harder. Cervical evaluation during labour may be impeded and labour prolonged or obstructed. Third-degree laceration (tears), anal-sphincter damage and emergency caesarean section are more common in infibulated women.Rashid and Rashid 2007, p. 97.
Neonatal mortality is increased. The WHO estimated in 2006 that an additional 10–20 babies die per 1,000 deliveries as a result of FGM. The estimate was based on a study conducted on 28,393 women attending delivery wards at 28 obstetric centres in Burkina Faso, Ghana, Kenya, Nigeria, Senegal and Sudan. In those settings all types of FGM were found to pose an increased risk of death to the baby: 15 percent higher for Type I, 32 percent for Type II and 55 percent for Type III. The reasons for this were unclear, but may be connected to genital and urinary-tract infections and the presence of scar tissue. The researchers wrote that FGM was associated with an increased risk to the mother of damage to the perineum and excessive blood loss, as well as a need to resuscitate the baby, and stillbirth, perhaps because of a long second stage of labour.Emily Banks, et al, "Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries", The Lancet, 367(9525), 3 June 2006, pp. 1835–1841. "New study shows female genital mutilation exposes women and babies to significant risk at childbirth", World Health Organization, 2 June 2006.
===Psychological effects, sexual function===
According to a 2015 systematic review there is little high-quality information available on the psychological effects of FGM. Several small studies have concluded that women with FGM suffer from anxiety, depression and post-traumatic stress disorder. Feelings of shame and betrayal can develop when women leave the culture that practises FGM and learn that their condition is not the norm, but within the practising culture they may view their FGM with pride, because for them it signifies beauty, respect for tradition, chastity and hygiene.
Studies on sexual function have also been small. A 2013 meta-analysis of 15 studies involving 12,671 women from seven countries concluded that women with FGM were twice as likely to report no sexual desire and 52 percent more likely to report dyspareunia (painful sexual intercourse). One third reported reduced sexual feelings.Rigmor C. Berg, Eva Denison, "A Tradition in Transition: Factors Perpetuating and Hindering the Continuance of Female Genital Mutilation/Cutting (FGM/C) Summarized in a Systematic Review", Health Care for Women International, 34(10), March 2013. .
For a summary of Berg and Denison, see Reisel and Creighton 2015, p. 51.
Also see S. Sibiani and A. A. Rouzi, "Sexual function in women with female genital mutilation", Fertility and Sterility, 93(3), September 2008, pp. 722–724. 
==Distribution==
===Prevalence===
FGM is mostly found in what political scientist Gerry Mackie describes as an "intriguingly contiguous" zone in Africa – east to west from Somalia to Senegal, and north to south from Egypt to Tanzania.Gerry Mackie, John LeJeune, "Social Dynamics of Abandonment of Harmful Practices: A New Look at the Theory", Innocenti Working Paper No. 2008-XXX, UNICEF Innocenti Research Centre, 2008, p. 5. As of 2014, 133 million women and girls were thought to be living with FGM in the 29 countries in which it is concentrated. If the rate of decline (as of 2014) continues, this figure will increase to 196 million by 2050 because of population growth.UNICEF 2014, p. 3: "If there is no reduction in the practice between now and 2050, the number of girls cut each year will grow from 3.6 million in 2013 to 6.6 million in 2050. But if the rate of progress achieved over the last 30 years is maintained, the number of girls affected annually will go from 3.6 million today to 4.1 million in 2050."In either scenario, the total number of girls and women cut will continue to increase due to population growth. If nothing is done, the number of girls and women affected will grow from 133 million today to 325 million in 2050. However, if the progress made so far is sustained, the number will grow from 133 million to 196 million in 2050, and almost 130 million girls will be spared this grave assault to their human rights."
Egypt, Ethiopia and Nigeria had the highest number of women and girls living with FGM as of 2013: 27.2 million, 23.8 million and 19.9 million respectively.UNICEF 2013, p. 2. (Egypt outlawed FGM in 2007, Ethiopia in 2004 and Nigeria in 2015.)UNFPA–UNICEF 2012, p. 12."National Legislation, Decrees and Statements Banning FGM/C", UNFPA Egypt.Alexandra Topping, "Nigeria's female genital mutilation ban is important precedent, say campaigners", The Guardian, 29 May 2015. In 2014 prevalence rates for women in sub-Saharan Africa were 39 percent and for girls aged 0–14, 17 percent. For Eastern and Southern Africa the figures were 44 and 14 percent, and for West and Central Africa 31 and 17 percent.
Prevalence figures are based on household surveys known as Demographic and Health Surveys (DHS), developed by Macro International and funded mainly by the United States Agency for International Development (USAID), and Multiple Indicator Cluster Surveys (MICS), conducted with financial and technical help from UNICEF.Yoder, Wang and Johansen, 2013, p. 190. These have been carried out in Africa, Asia, Latin America and elsewhere roughly every five years, since 1984 and 1995 respectively.UNICEF 2013, Box 1.1, p. 4.Yoder, Wang and Johansen, 2013, p. 190; "DHS overview", Demographic and Health Surveys; "Questionnaires and Indicator List", Multiple Indicator Cluster Surveys, UNICEF.
The first survey to ask about FGM was the 1989–1990 DHS in northern Sudan, and the first publication to estimate FGM prevalence based on DHS data (in seven countries) was by Dara Carr of Macro International in 1997.Yoder, Wang and Johansen, 2013, p. 191; Dara Carr, Female genital cutting: Findings from the Demographic and Health Surveys program, Calverton, MD: Macro International Inc., 1997. A UNICEF report based on over 70 of these surveys concluded in 2013 that FGM was concentrated in 27 African countries, Yemen and Iraqi Kurdistan,UNICEF 2013, pp. 3, 5. and that 133 million women and girls in those 29 countries had experienced it.Female Genital Mutilation/Cutting: What Might the Future Hold?, New York: UNICEF, 22 July 2014 (hereafter UNICEF 2014), pp. 3, 6.
Outside the 29 key countries, FGM has been documented in India, the United Arab Emirates, among the Bedouin in Israel, and reported by anecdote in Colombia, Congo, Oman, Peru and Sri Lanka.WHO 2008, pp. 29–30. It is also practised in Jordan, Saudi Arabia, Indonesia and Malaysia, and within immigrant communities around the world, including Australia, New Zealand, Europe, the United States and Canada.UNICEF 2013, p. 23: "Although no nationally representative data on FGM/C are available for countries including Colombia, Jordan, Oman, Saudi Arabia and parts of Indonesia and Malaysia, evidence suggests that the procedure is being performed."
For Australia, New Zealand, Europe, Scandinavia, the United States and Canada, UNICEF 2005, p. 4.
===Ethnicity===
A country's national prevalence often reflects a high sub-national prevalence among certain ethnicities, rather than a widespread practice.UNICEF 2013, pp. 28–37. In Iraq, for example, FGM is found mostly among the Kurds in Erbil (58 percent prevalence within age group 15–49), Sulaymaniyah (54 percent) and Kirkuk (20 percent), giving the country a national prevalence of eight percent.UNICEF 2013, pp. 27 (for eight percent), 31 (for the regions).
Berivan A. Yasin, et al, "Female genital mutilation among Iraqi Kurdish women: a cross-sectional study from Erbil city", BMC Public Health, 13, September 2013. 
The practice is sometimes an ethnic marker, but may differ along national lines. In the northeastern regions of Ethiopia and Kenya, which share a border with Somalia, the Somali people practise FGM at around the same rate as they do in Somalia.Yoder, Wang and Johansen, 2013, p. 196, 198. But in Guinea all Fulani women responding to a survey in 2012 said they had experienced FGM,"Guinea" (2012), UNICEF statistical profile, July 2014, p. 2/4. against 12 percent of the Fulani in Chad, while in Nigeria the Fulani are the only large ethnic group in the country not to practise it.For Chad, UNICEF 2013, pp. 35–36; for Nigeria, T. C. Okeke, et al, "An Overview of Female Genital Mutilation in Nigeria", Annals of Medical Health Sciences Research, 2(1), Jan–June 2012, pp. 70–73. FGM is practised in Nigeria by the Yoruba, Hausa, Ibo, Ijaw and Kanuri people.
===Rural areas, wealth, education===
Surveys have found FGM to be more common in rural areas, less common in most countries among girls from the wealthiest homes, and (except in Sudan and Somalia) less common in girls whose mothers had access to primary or secondary/higher education. In Somalia and Sudan the situation was reversed: in Somalia the mothers' access to secondary/higher education was accompanied by a rise in prevalence of FGM in their daughters, and in Sudan access to any education was accompanied by a rise.For rural areas, UNICEF 2013, p. 28; for wealth, p. 40; for education, p. 41.
===Type of FGM===
Women are asked during surveys about the type of FGM they experienced:UNICEF 2013, p. 134–135.
* Was the genital area just nicked/cut without removing any flesh?
* Was any flesh (or something) removed from the genital area?
* Was your genital area sewn?
Most affected women experience one of the "cut, some fleshed removed" procedures, which embrace WHO Types I and II. Types I and II are both performed in Egypt.Mohammed A. Tag-Eldin, "Prevalence of female genital cutting among Egyptian girls", Bulletin of the World Health Organization, 86(4), April 2008: "The most common forms of FGC still widely practised throughout Egypt are type I (commonly referred to as clitoridectomy) and type II (commonly referred to as excision)." Mackie wrote in 2003 that Type II was more common there,Gerry Mackie, "Female Genital Cutting: A Harmless Practice?", Medical Anthropology Quarterly, 17(2), 2003 (pp. 135–158), p. 148. while a 2011 study identified Type I as more common. In Nigeria Type I is usually found in the south and the more severe forms in the north.For north and south, Okeke, et al 2012, pp. 70–73.
Type III (infibulation) is concentrated in northeastern Africa, particularly Djibouti, Eritrea, Somalia and Sudan.Yoder and Khan 2008, pp. 13–14. In surveys in 2002–2006, 30 percent of cut girls in Djibouti had experienced Type III, 38 percent in Eritrea and 63 percent in Somalia.UNICEF 2013, p. 47, Table 5.2.
For the years, see UNICEF FGM statistical profiles: Djibouti, December 2013: "Source for all charts on this page: MICS 2006"; Eritrea, July 2014, p. 2/4: "Source: DHS 2002"; Somalia, December 2013, p. 2/4: "Source for all charts on this page: MICS 2006." There is also a high prevalence of infibulation among girls in Niger and Senegal,UNICEF 2013, p. 114: "In Somalia, Eritrea, Niger, Djibouti and Senegal, more than one in five girls have undergone the most radical form of the practice known as infibulation ..." and in 2013 it was estimated that in Nigeria three percent of the 0–14 age group had been infibulated."Nigeria: Statistical profile on female genital mutilation/cutting", UNICEF, July 2014. The type of procedure is often linked to ethnicity. In Eritrea, for example, a survey in 2002 found that all Hedareb girls had been infibulated, compared with two percent of the Tigrinya, most of whom fell into the "cut, no flesh removed" category.UNICEF 2013, p. 48.
===Age conducted===
FGM is not invariably a rite of passage between childhood and adulthood, but is often performed on much younger children.Gerry Mackie, "Female Genital Cutting: The Beginning of the End", in Shell-Duncan and Hernlund 2000 (pp. 253–282), p. 275. Girls are most commonly cut shortly after birth to age 15. In half the countries for which national figures were available in 2000–2010, most girls had been cut by age five. Over 80 percent (of those cut) are cut before that age in Nigeria, Mali, Eritrea, Ghana and Mauritania. The 1997 Demographic and Health Survey in Yemen found that 76 percent of girls had been cut within two weeks of birth.UNICEF 2005, p. 6.
The percentage is reversed in Somalia, Egypt, Chad and the Central African Republic, where over 80 percent (of those cut) are cut between five and 14.UNICEF 2013, pp. 47, 183. Just as the type of FGM is often linked to ethnicity, so is the mean age; in Kenya, for example, the Kisi cut around age 10 and the Kamba at 16.UNICEF 2013, p. 51.
===Changes in prevalence===
In 2013 UNICEF reported a downward trend in over half the 29 key countries in the 15–19 group compared to women aged 45–49.UNICEF 2013, p. 99. Little difference was found in countries with very high prevalence, but the rate of FGM had declined in countries with lower prevalence, or less severe forms of FGM were being practised.Yoder, Wang and Johansen, 2013, p. 193; UNICEF 2013, pp. 99, 114. According to UNICEF in 2014, the likelihood of a girl experiencing FGM was overall one third lower than 30 years ago.UNICEF 2014, p. 2.
Women who respond to surveys on FGM are reporting events experienced years ago, so prevalence figures for the 15–49 group do not reflect current trends.UNICEF 2013, pp. 85, 113. UNICEF bases its figures on the 15–49 group because girls are generally at risk until they are 14.UNICEF 2013, p. 23: "The percentage of girls and women of reproductive age (15 to 49) who have experienced any form of FGM/C is the first indicator used to show how widespread the practice is in a particular country ... A second indicator of national prevalence measures the extent of cutting among daughters aged 0 to 14, as reported by their mothers. Prevalence data for girls reflect their current – not final – FGM/C status, since many of them may not have reached the customary age for cutting at the time of the survey. They are reported as being uncut but are still at risk of undergoing the procedure. Statistics for girls under age 15 therefore need to be interpreted with a high degree of caution ..." An additional complication in judging prevalence among girls is that, in countries running campaigns against FGM, women might not report that their daughters have been cut.UNICEF 2013, pp. 25, 100; Yoder, Wang and Johansen, 2013, p. 196.
In 2010 the DHS and MICS surveys began asking women about the FGM status of all their living daughters.Yoder, Wang and Johansen, 2013, p. 194; UNICEF 2013, p. 25. As of 2014 (right), the surveys suggested a prevalence for the 0–14 age group of 0.3 percent in Benin at the lowest (7 percent for the 15–49 group) to 74 percent in Mali (89 percent for 15–49).
In a study in Egypt in 2008–2010 (FGM was banned there by decree in 2007 and criminalized in 2008), 4,158 women and girls aged 5–25, who presented to three departments at Sohag and Qena University Hospitals, replied to a questionnaire about FGM. According to the researchers, the most common form of FGM in Egypt is Type I. The study found that, between 2000 and 2009, 3,711 of the subjects had undergone FGM, giving a prevalence rate of 89.2 percent. The incidence rate was 9.6 percent in 2000. It began to fall in 2006 and by 2009 had declined to 7.7 percent. After 2007 most of the procedures were conducted by general practitioners. The researchers suggested that the criminalization of FGM had deterred gynaecologists, so general practitioners were performing it instead.Salah M. Rasheedemail, Ahmed H. Abd-Ellah, Fouad M. Yousef, "Female genital mutilation in Upper Egypt in the new millennium", International Journal of Gynecology and Obstetrics, 114(1), July 2011, pp. 47–50: "From 2000 to 2009, 3711 of the young participants (89.2%) underwent FGM and 447 (10.8%) did not. The mean age at the time of FGM was 8.2 ± 0.9 years. About three quarters (74.3%) of the procedures were performed at home and the remaining 25.7% at private clinics." 
==Reasons==
===Support from women===
Dahabo Musa, a Somali woman, described infibulation in a 1988 poem as the "three feminine sorrows": the procedure itself, the wedding night when the woman is cut open, then childbirth when she is cut again.Abdalla 2007, p. 187. Despite the evident suffering, it is women who organize all forms of FGM, including infibulation. Anthropologist Rose Oldfield Hayes wrote in 1975 that educated Sudanese men living in cities who did not want their daughters to be infibulated (preferring clitoridectomy) would find the girls had been sewn up after their grandmothers arranged a visit to relatives.Hayes 1975, pp. 620, 624. Gerry Mackie compares FGM to footbinding. Like FGM, footbinding was carried out on young girls, nearly universal where practised, tied to ideas about honour, chastity and appropriate marriage, and supported by women.Gerry Mackie, "Ending Footbinding and Infibulation: A Convention Account", American Sociological Review, 61(6), December 1996 (pp. 999–1017), pp. 999–1000: "Footbinding and infibulation correspond as follows. Both customs are nearly universal where practiced; they are persistent and are practiced even by those who oppose them. Both control sexual access to females and ensure female chastity and fidelity. Both are necessary for proper marriage and family honor. Both are believed to be sanctioned by tradition. Both are said to be ethnic markers, and distinct ethnic minorities may lack the practices. Both seem to have a past of contagious diffusion. Both are exaggerated over time and both increase with status. Both are supported and transmitted by women, are performed on girls about six to eight years old, and are generally not initiation rites. Both are believed to promote health and fertility. Both are defined as aesthetically pleasing compared with the natural alternative. Both are said to properly exaggerate the complementarity of the sexes, and both are claimed to make intercourse more pleasurable for the male."
Also see Mackie 2000, p. 256.
Practitioners see the procedures as marking not only community boundaries but also gender difference. According to this view, FGM demasculinizes women, while male circumcision defeminizes men.Rogaia Mustafa Abusharaf, "Introduction: The Custom in Question," in Abusharaf 2007, p. 8; El Guindi 2007, pp. 36–37. Fuambai Ahmadu, an anthropologist and member of the Kono people of Sierra Leone, who underwent clitoridectomy as an adult during a Sande society initiation, argues that the idea of the clitoris as important to female sexuality is a male-centred assumption. African female symbolism revolves instead around the concept of the womb.Fuambai Ahmadu, "Rites and Wrongs: An Insider/Outsider Reflects on Power and Excision," in Shell-Duncan and Hernlund 2000, pp. 284–285. Infibulation draws on that idea of enclosure and fertility. "[G]enital cutting completes the social definition of a child's sex by eliminating external traces of androgyny," writes Janice Boddy. "The female body is then covered, closed, and its productive blood bound within; the male body is unveiled, opened and exposed."Janice Boddy, Civilizing Women: British Crusades in Colonial Sudan, Princeton: Princeton University Press, 2007, pp. 112. Also see Silverman 2004, p. 429.
In communities where infibulation is common, there is a preference for women's genitals to be smooth, dry and without odour, and both women and men may find the natural vulva repulsive.Ellen Gruenbaum, "Socio-Cultural Dynamics of Female Genital Cutting: Research Findings, Gaps, and Directions", Culture, Health & Sexuality, 7(5), September–October 2005 (pp. 429–441), pp. 435–436. Men seem to enjoy the effort of penetrating an infibulation.Gruenbaum 2005, p. 437; Gruenbaum 2001, p. 140; Janice Boddy, Wombs and Alien Spirits: Women, Men, and the Zar Cult in Northern Sudan, Madison: University of Wisconsin Press, 1989, p. 52. There is also a belief, because of the smooth appearance of an infibulated vulva, that infibulation increases hygiene.Gruenbaum 2005, p. 437. Women regularly introduce substances into the vagina to reduce lubrication, including leaves, tree bark, toothpaste and Vicks menthol rub. The WHO includes this practice within Type IV FGM, because the added friction during intercourse can cause lacerations and increase the risk of infection.Bagnol and Mariano 2011, pp. 277–281; for Type IV, WHO 2008, pp. 27–28.
Common reasons for FGM cited by women in surveys are social acceptance, religion, hygiene, preservation of virginity, marriageability and enhancement of male sexual pleasure.UNICEF 2013, p. 67. In a study in northern Sudan, published in 1983, only 558 (17.4 percent) of 3,210 women opposed FGM, and most preferred excision and infibulation over clitoridectomy.Asma El Dareer, "Attitudes of Sudanese People to the Practice of Female Circumcision", International Journal of Epidemiology, 12(2), 1983 (pp. 138–144), p. 140. Attitudes are slowly changing. In Sudan in 2010 42 percent of women who had heard of FGM said the practice should continue.UNICEF 2013, p. 178. In several surveys since 2006, over 50 percent of women in Mali, Guinea, Sierra Leone, Somalia, Gambia and Egypt supported FGM's continuance, while elsewhere in Africa, Iraq and Yemen most said it should end, though in several countries only by a narrow margin.UNICEF 2013, p. 52: "The highest levels of support can be found in Mali, Guinea, Sierra Leone, Somalia, Gambia and Egypt, where more than half the female population think the practice should continue." Also see Figure 6.1, p. 54 and Figures 8.1A – 8.1D, pp. 90–91.
===Social obligation===
Against the argument that women willingly choose FGM for their daughters, UNICEF calls the practice a "self-enforcing social convention" to which families feel they must conform to avoid uncut daughters facing social exclusion.UNICEF 2013, p. 15.
Ellen Gruenbaum reports that, in the 1970s, cut girls from an Arab ethnic group in Sudan would mock uncut girls from the Zabarma people, shouting at them Ya, Ghalfa! ("Hey, unclean!"). The Zabarma girls would respond with their own taunt, Ya, mutmura! (a mutmara was a storage pit for grain that was continually opened and closed, like an infibulated woman). But the Zabarma girls felt the pressure, asking their mothers, "What's the matter? Don't we have razor blades like the Arabs?"Gruenbaum 2005, pp. 432–433.
Because of poor access to information, and because circumcisers downplay the causal connection, women may not associate the health consequences with the procedure. Lala Baldé, president of a women's association in Medina Cherif, a village in Senegal, told Mackie in 1998 that when girls fell ill or died, it was attributed to evil spirits. When informed of the causal relationship between FGM and ill health, Mackie writes, the women broke down and wept. He argues that surveys taken before and after this sharing of information would show very different levels of support for FGM.Mackie 2003, pp. 147–148.
The American non-profit group Tostan, founded by Molly Melching in 1991, has introduced community-empowerment programmes in several countries that focus on literacy, education about healthcare and local democracy, giving women the tools to make their own decisions.UNICEF-UNFPA 2012, pp. 21–22.
Nafissatou J. Diop, Amadou Moreau, Hélène Benga, "Evaluation of the Long-term Impact of the TOSTAN Programme on the Abandonment of FGM/C and Early Marriage: Results from a qualitative study in Senega", UNICEF, January 2008.
Louisa Kasdon, "A Tradition No Longer", World & I, November–December 2005, pp. 66–73.
Jean Faraca, "Confronting Female Genital Cutting", Wisconsin Public Radio, interview with Molly Melching and Gerry Mackie, 3 November 2011, from 2:43 mins. In 1997, using the Tostan programme, Malicounda Bambara in Senegal became the first village to abandon FGM, and by 2014 over 7,000 communities in eight countries had pledged to abandon FGM and child marriage.For Malicounda Bambara, Mackie 2000, p. 256ff; for over 7,000 communities, "Our Success", Tostan, accessed 25 October 2014. A UNFPA-UNICEF joint programme, underway in 15 African countries , is modelled along similar lines.
===Religion===
Surveys have shown a widespread belief, particularly in Mali, Mauritania, Guinea and Egypt, that FGM is a religious requirement.UNICEF 2013, pp. 69–70; Figure 6.12, p. 71. Gruenbaum has argued that practitioners may not distinguish between religion, tradition and chastity, making it difficult to interpret the data.Gruenbaum 2001, p. 50; Mackie and LeJeune 2008, p. 8. As part of UNFPA–UNICEF's joint programme, 20,941 religious and traditional leaders made public declarations between 2008 and 2013 delinking their religions from the practice, and religious leaders issued 2,898 edicts against it.UNFPA-UNICEF Joint Programme on Female Genital Mutilation/Cutting: Accelerating Change, Summary Report of Phase I, 2008–2013 (hereafter 2013 UNFPA-UNICEF Joint Programme evaluation), p. 26.
Although FGM's origins in northeastern Africa are pre-Islamic, the practice became associated with Islam because of that religion's focus on female chastity and seclusion.Mackie 1996, p. 1008: "FGM is pre-Islamic but was exaggerated by its intersection with the Islamic modesty code of family honor, female purity, virginity, chastity, fidelity, and seclusion." There is no mention of it in the Qur'an. It is praised in several hadith (sayings attributed to Muhammad) as noble but not required, along with advice that the milder forms are kinder to women.Mackie 1996, pp. 1004–1005: "The Koran is silent on FGM, but several hadith (sayings attributed to Mohammed) recommend attenuating the practice for the woman's sake, praise it as noble but not commanded, or advise that female converts refrain from mutilation because even if pleasing to the husband it is painful to the wife."
Also see Ibrahim Lethome Asmani, Maryam Sheikh Abdi, "De-linking Female Genital Mutilation/Cutting from Islam", USAID/UNFPA, 2008. In 2007 the Al-Azhar Supreme Council of Islamic Research in Cairo ruled that FGM had "no basis in core Islamic law or any of its partial provisions.""Fresh progress toward the elimination of female genital mutilation and cutting in Egypt", UNICEF, 2 July 2007; UNICEF 2013, p. 70.
Maggie Michael, "Egypt Officials Ban Female Circumcision", The Associated Press, 29 June 2007, p. 2: "[Egypt's] supreme religious authorities stressed that Islam is against female circumcision. It's prohibited, prohibited, prohibited," Grand Mufti Ali Gomaa said on the privately owned al-Mahwar network."
FGM is also practised by animist groups, particularly in Guinea and Mali, and by Christians.For animist groups, UNICEF 2013, p. 175; for Christians, p. 73. In Niger, for example, 55 percent of Christian women and girls have experienced FGM, compared with two percent of their Muslim counterparts.UNICEF 2013, front page: "Niger. 55% of Christian girls and women have undergone FGM/C, compared to 2% of Muslim girls and women," and p. 73. There is no mention of FGM in the Bible, and Christian missionaries in Africa were among the first to object to it.Samuel Waje Kunhiyop, African Christian Ethics, Zondervan, 2008, p. 297: "Nowhere in all of Scripture or in any of recorded church history is there even a hint that women were to be circumcised."
For missionaries, Jocelyn Murray, "The Church Missionary Society and the 'Female Circumcision' Issue in Kenya 1929–1932", Journal of Religion in Africa, 8(2), 1976, pp. 92–104. The only Jewish group known to have practised it are the Beta Israel of Ethiopia; Judaism requires male circumcision, but does not allow FGM.Shaye J. D. Cohen, Why Aren't Jewish Women Circumcised? Gender and Covenant In Judaism, Berkeley: University of California Press, 2005, p. 59; Adele Berlin (ed.), "Circumcision," The Oxford Dictionary of the Jewish Religion, New York: Oxford University Press, 2011, p. 173.
==History==
===Antiquity===
The origins of the practice are unknown.Mackie 1996, p. 1003; Abusharaf 2007, p. 2. Its east-west, north-south distribution in Africa meets in Sudan, leading Gerry Mackie to speculate that infibulation originated with the Meroite civilization and imperial polygyny, before the rise of Islam, to increase confidence in paternity.Mackie 2000, pp. 264, 267; UNICEF 2013, p. 30; Shell-Duncan and Hernlund 2000, p. 13; Mackie 1996, p. 1003.
Also see C. G. Seligman, "Aspects of the Hamitic problems in the Anglo-Egyptian Sudan",The Journal of the Royal Anthropological Institute of Great Britain and Ireland, 1913, 40(3), (pp. 593–705), pp. 639–646; Esther K. Hicks, Infibulation: Female Mutilation in Islamic Northeastern Africa, Transaction Publishers, 1996, p. 19ff.
According to historian Mary Knight, Spell 1117 (c. 1991–1786 BCE) of the Ancient Egyptian Coffin Texts may refer in hieroglyphs to an uncircumcised girl ('m't):
a-m-a:X1-D53-B1
The spell was found on the sarcophagus of Sit-hedjhotep, now in the Egyptian Museum, and dates to Egypt's Middle Kingdom. (Paul F. O'Rourke argues that 'm't probably refers instead to a menstruating woman.)Knight 2001, p. 330. Knight adds that Egyptologists are uncomfortable with the translation to uncircumcised, because there is no information about what constituted the circumcised state.
Paul F. O'Rourke, "The 'm't-Woman", Zeitschrift für Ägyptische Sprache und Altertumskunde, 134(2), February 2007 (pp. 166–172), pp. 166ff (hieroglyphs), 172 (menstruating woman). 
The proposed circumcision of an Egyptian girl, Tathemis, is mentioned on a Greek papyrus from 163 BCE in the British Museum:
Sometime after this, Nephoris [Tathemis's mother] defrauded me, being anxious that it was time for Tathemis to be circumcised, as is the custom among the Egyptians. She asked that I give her 1,300 drachmae ... to clothe her ... and to provide her with a marriage dowry ... if she didn't do each of these or if she did not circumcise Tathemis in the month of Mecheir, year 18 [163 BCE], she would repay me 2,400 drachmae on the spot.Knight 2001, pp. 329–330; F. G. Kenyon, Greek Papyri in the British Museum, British Museum, 1893, pp. 31–32 (also here).
The examination of mummies has shown no evidence of FGM. Citing the Australian pathologist Grafton Elliot Smith, who examined hundreds of mummies in the early 20th century, Knight writes that the genital area may resemble Type III, because during mummification the skin of the outer labia was pulled toward the anus to cover the pudendal cleft, possibly to prevent sexual violation. It was similarly not possible to determine whether Types I or II had been performed, because soft tissues had been removed by the embalmers or had deteriorated.Knight 2001, p. 331, citing G. Elliot Smith, A Contribution to the Study of Mummification in Egypt, 1906, p. 30.
Knight quotes Marc Armand Ruffer, Studies in the Paleopathology of Egypt, Chicago: University of Chicago Press, 1921, p. 171: "[T]he bodies are in such a state that it would often be difficult to state with certainty whether such an operation had been done." Knight adds: "In light of the fact that only rarely have scientific researchers autopsying mummies specifically looked for the presence or absence of FGM, conclusive remarks about the prevalence of the practice must await a detailed study of a large cohort of female mummies."
The Greek geographer Strabo (c. 64 BCE – c. 23 CE) wrote about FGM after visiting Egypt around 25 BCE (right). The philosopher Philo of Alexandria (c. 20 BCE – 50 CE) also made reference to it: "the Egyptians by the custom of their country circumcise the marriageable youth and maid in the fourteenth (year) of their age, when the male begins to get seed, and the female to have a menstrual flow."Knight 2001, p. 333. It is mentioned briefly in a work attributed to the Greek physician Galen (129 – c. 200 CE): "When [the clitoris] sticks out to a great extent in their young women, Egyptians consider it appropriate to cut it out."Knight 2001, p. 326 (Knight writes that the attribution to Galen is suspect).
Another Greek physician, Aëtius of Amida (mid-5th to mid-6th century CE), offered more detail in book 16 of his Sixteen Books on Medicine, citing the physician Philomenes. The procedure was performed in case the clitoris, or nymphê, grew too large or triggered sexual desire when rubbing against clothing. "On this account, it seemed proper to the Egyptians to remove it before it became greatly enlarged," Aëtius wrote, "especially at that time when the girls were about to be married":
The surgery is performed in this way: Have the girl sit on a chair while a muscled young man standing behind her places his arms below the girl's thighs. Have him separate and steady her legs and whole body. Standing in front and taking hold of the clitoris with a broad-mouthed forceps in his left hand, the surgeon stretches it outward, while with the right hand, he cuts it off at the point next to the pincers of the forceps.
It is proper to let a length remain from that cut off, about the size of the membrane that's between the nostrils, so as to take away the excess material only; as I have said, the part to be removed is at that point just above the pincers of the forceps. Because the clitoris is a skinlike structure and stretches out excessively, do not cut off too much, as a urinary fistula may result from cutting such large growths too deeply.Knight 2001, pp. 327–328 (a paragraph break has been added for ease of reading).
The genital area was then cleaned with a sponge, frankincense powder and wine or cold water, and wrapped in linen bandages dipped in vinegar, until the seventh day when calamine, rose petals, date pits or a "genital powder made from baked clay" might be applied.Knight 2001, p. 328.
Whatever the practice's origins, infibulation became linked to slavery. Mackie cites the Portuguese missionary João dos Santos, who in 1609 wrote of a group inland from Mogadishu who had a "custome to sew up their Females, especially their slaves being young to make them unable for conception, which makes these slaves sell dearer, both for their chastitie, and for better confidence which their Masters put in them." The English explorer William Browne wrote in 1799 that the Egyptians practised excision, and that slaves in that country were infibulated to prevent pregnancy.Mackie 1996, p. 1003. Thus, Mackie argues, a "practice associated with shameful female slavery came to stand for honor."Mackie 1996, p. 1009.
===Europe and the United States===
Gynaecologists in 19th-century Europe and the United States removed the clitoris to treat insanity and masturbation.Sarah W. Rodriguez, "Rethinking the History of Female Circumcision and Clitoridectomy: American Medicine and Female Sexuality in the Late Nineteenth Century", Journal of the History of Medicine and Allied Sciences. 63(3), July 2008, pp. 323–347. British doctor Robert Thomas suggested clitoridectomy as a cure for nymphomania in 1813.Robert Thomas, The Modern Practice of Physick, London: Longman, Hurst, Rees, Orme, and Brown, 1813, pp. 585–586.
Edward Shorter, From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era, New York: Simon and Schuster, 2008, p. 82. The first reported clitoridectomy in the West, described in The Lancet in 1825, was performed in 1822 in Berlin by Karl Ferdinand von Graefe on a 15-year-old girl who was masturbating excessively.Shorter 2008, p. 82; Uriel Elchalal, et al., "Ritualistic Female Genital Mutilation: Current Status and Future Outlook", Obstetrical & Gynecological Survey, 52(10), October 1997, pp. 643–651. 
Isaac Baker Brown, an English gynaecologist, president of the Medical Society of London, and co-founder in 1845 of St. Mary's Hospital in London, believed that masturbation, or "unnatural irritation" of the clitoris, caused peripheral excitement of the pubic nerve, which led to hysteria, spinal irritation, fits, idiocy, mania and death.Elchalal, et al, 1997; Peter Lewis Allen, The Wages of Sin: Sex and Disease, Past and Present, Chicago: University of Chicago Press, 2000, p. 106. He therefore "set to work to remove the clitoris whenever he had the opportunity of doing so," according to his obituary in the Medical Times and Gazette in 1873.J. F. C. 1873, p. 155; Allen 2000, p. 106. Brown performed several clitoridectomies between 1859 and 1866. When he published his views in On the Curability of Certain Forms of Insanity, Epilepsy, Catalepsy, and Hysteria in Females (1866), doctors in London accused him of quackery and expelled him from the Obstetrical Society.John Black, "Female genital mutilation: a contemporary issue, and a Victorian obsession", Journal of the Royal Society of Medicine, 90, July 1997 (pp. 402–405), p. 403, 404–405. 
Allen 2000, p. 106; also see Elizabeth Sheehan, "Victorian Clitoridectomy: Isaac Baker Brown and His Harmless Operative Procedure", Medical Anthropology Newsletter, 12(4), August 1981. 
In the United States J. Marion Sims followed Brown's work, and in 1862 slit the neck of a woman's uterus and amputated her clitoris, "for the relief of the nervous or hysterical condition as recommended by Baker Brown," after the patient complained of menstrual pain, convulsions and bladder problems.Deborah Kuhn McGregor, From Midwives to Medicine: The Birth of American Gynecology, New Brunswick: Rutgers University Press, 1998, p. 146. Later that century A. J. Bloch, a surgeon in New Orleans, removed the clitoris of a two-year-old girl who was reportedly masturbating.John Milton Hoberman, Testosterone Dreams: Rejuvenation, Aphrodisia, Doping, University of California Press, 2005, p. 63. According to a 1985 paper in the Obstetrical & Gynecological Survey, clitoridectomy was performed in the US into the 1960s to treat hysteria, erotomania and lesbianism.Lawrence Cutner, "Female genital mutilation", Obstetrical & Gynecological Survey, 40(7), July 1985, pp. 437–443. Cited in Nawal M. Nour, "Female Genital Cutting: A Persisting Practice", Reviews in Obstetrics and Gynecology, 1(3), Summer 2008, pp. 135–139. Also see G. J. Barker-Benfield, The Horrors of the Half-Known Life: Male Attitudes Toward Women and Sexuality in Nineteenth-Century America, New York: Routledge, 1999, p. 113.
==Opposition==
===Colonial opposition in Kenya===
Protestant missionaries in British East Africa (present-day Kenya), began campaigning against FGM in the early 20th century when Dr. John Arthur joined the Church of Scotland Mission (CSM) in Kikuyu. The practice was known by the Kikuyu, the country's main ethnic group, as irua for both girls and boys, and involved excision (Type II) for girls and removal of the foreskin for boys. It was an important ethnic marker, and unexcised Kikuyu women, known as irugu, were outcasts.Lynn M. Thomas,Ngaitana (I will circumcise myself)': Lessons from Colonial Campaigns to Ban Excision in Meru, Kenya" in Shell-Duncan and Hernlund, 2000, p. 132.
For irua, Jomo Kenyatta, Facing Mount Kenya, New York: Vintage Books, 1962 [1938], p. 129; for irugu being outcasts, Kenyatta, p. 127, and Zabus 2008, pp. 48–49.
Jomo Kenyatta, general secretary of the Kikuyu Central Association and Kenya's first prime minister from 1963, wrote in 1938 that, for the Kikuyu, the institution of FGM was the "conditio sine qua non of the whole teaching of tribal law, religion and morality." No proper Kikuyu man or woman would marry or have sexual relations with someone who was not circumcised. A woman's responsibilities toward the tribe began with her initiation. Her age and place within tribal history was traced to that day, and the group of girls with whom she was cut was named according to current events, an oral tradition that allowed the Kikuyu to track people and events going back hundreds of years.Kenyatta 1962 [1938], pp. 127–130.
From 1925, beginning with the CSM mission, several missionary churches declared that FGM was prohibited for African Christians. The CSM announced that Africans practising it would be excommunicated, resulting in hundreds leaving or being expelled.Klaus Fiedler, Christianity and African Culture, Leiden: Brill, 1996, p. 75. The stand-off turned FGM into a focal point of the Kenyan independence movement; the 1929–1931 period is known in the country's historiography as the female circumcision controversy.Boddy 2007, pp. 241–245.
Also see Ronald Hyam, Empire and Sexuality: The British Experience, Manchester: Manchester University Press, 1990; Murray 1976, pp. 92–104.
In 1929 the Kenya Missionary Council began referring to FGM as the "sexual mutilation of women," rather than circumcision, and a person's stance toward the practice became a test of loyalty, either to the Christian churches or to the Kikuyu Central Association.Thomas 2000, p. 132; for the "sexual mutilation of women," Karanja 2009, p. 93, n. 631.
Also see Robert Strayer, Jocelyn Murray, "The CMS and Female Circumcision," in Robert Strayer (ed.), The Making of Missionary Communities in East Africa, New York: State University of New York Press, 1978, p. 139ff. Hulda Stumpf, an American missionary with the Africa Inland Mission who opposed FGM in the girls' school she helped to run, was murdered in 1930. Edward Grigg, the governor of Kenya, told the British Colonial Office that the killer, who was never identified, had attempted to circumcise her.Boddy 2007, pp. 241, 244.
Dana Lee Robert, American Women in Mission: A Social History of Their Thought and Practice, Macon: Mercer University Press, 1996, p. 230.
In 1956 the council of male elders (the Njuri Nchecke) in Meru announced a ban on FGM. Over the next three years, as a symbol of defiance, thousands of girls cut each other's genitals with razor blades. The movement came to be known in Meru as Ngaitana ("I will circumcise myself"), because to avoid naming their friends the girls said they had cut themselves. Historian Lynn Thomas describes the episode as significant in the history of FGM because it made clear that its victims were also its perpetrators.Thomas 2000, pp. 129–131 (p. 131 for the girls as "central actors"); Lynn Thomas, Politics of the Womb: Women, Reproduction, and the State in Kenya, Berkeley: University of California Press, 2003, pp. 89–91.
Also see Lynn M. Thomas, Ngaitana (I will circumcise myself)': The Gender and Generational Politics of the 1956 Ban on Clitoridectomy in Meru, Kenya", Gender and History, 8(3), November 1996, pp. 338–363.
Kenya banned FGM in 2011; see UNICEF-UNFPA 2012, p. 14.
===Growth of opposition===
thumb|220px|alt=photograph|Nawal El Saadawi, one of the first African feminists to criticize FGM
The first known non-colonial campaign against FGM began in Egypt in the 1920s, when the Egyptian Doctors' Society called for a ban.UNICEF 2013, p. 10, calls the Egyptian Doctors' Society opposition the "first known campaign" against FGM; for independence, Boddy 2007, p. 147. There was a parallel campaign in Sudan, run by religious leaders and British women. Infibulation was banned there in 1946, but the law was unpopular and barely enforced.Boddy 2007, pp. 202, 299.
FGM is still practised in Sudan; some states banned it in 2008–2009, but , there was no national legislation (UNICEF 2013, pp. 2, 9). The Egyptian government banned infibulation in state-run hospitals in 1959, but allowed partial clitoridectomy if parents requested it.Elizabeth Heger Boyle, Female Genital Cutting: Cultural Conflict in the Global Community, Baltimore: Johns Hopkins University Press, 2002, pp. 92, 103. (Egypt banned FGM entirely in 2007.)
In 1959 the UN asked the WHO to investigate FGM, but the latter responded that it was not a medical matter.Boyle 2002, p. 41. Feminists took up the issue throughout the 1970s.Bagnol and Mariano 2011, p. 281. Egyptian physician Nawal El Saadawi's book, Women and Sex (1972), criticized FGM; the book was banned in Egypt and El Saadawi lost her job as director general of public health.Gruenbaum 2001, p. 22.
Homa Khaleeli, "Nawal El Saadawi: Egypt's radical feminist", The Guardian, 15 April 2010.
Jenna Krajeski, "The Books of Nawal El Saadawi", The New Yorker, 7 March 2011.
Jenna Krajeski, "Rebellion", The New Yorker, 14 March 2011. She followed up with a chapter, "The Circumcision of Girls", in The Hidden Face of Eve: Women in the Arab World (1980), which described her own clitoridectomy when she was six years old:
I did not know what they had cut off from my body, and I did not try to find out. I just wept, and called out to my mother for help. But the worst shock of all was when I looked around and found her standing by my side. Yes, it was her, I could not be mistaken, in flesh and blood, right in the midst of these strangers, talking to them and smiling at them, as though they had not participated in slaughtering her daughter just a few moments ago.Nawal El Saadawi, The Hidden Face of Eve, London: Zed Books, 2007 [1980], p. 14.
In 1975 the American social scientist Rose Oldfield Hayes became the first female academic to publish a detailed account of FGM, aided by her ability to discuss the issues directly with women in Sudan. Her article in American Ethnologist called it "female genital mutilation" and brought it to wider academic attention.Hayes 1975, p. 618; Gruenbaum 2001, p. 21.
Four years later Austrian-American feminist Fran Hosken published The Hosken Report: Genital and Sexual Mutilation of Females (1979), the first to estimate the global number of women cut. She wrote that 110,529,000 women in 20 African countries had experienced FGM.Yoder and Khan 2008, p. 2. The figures were speculative, but in several instances consistent with later surveys; Mackie writes that her work was "more informative than the silence that preceded her efforts."Mackie 2003, p. 139. Describing FGM as a "training ground for male violence," Hosken accused female practitioners of "participating in the destruction of their own kind."Hosken 1994 [1979], p. 5. The language caused a rift between Western and African feminists; African women boycotted a session featuring Hosken during the UN's Mid-Decade Conference on Women in Copenhagen in July 1980.Boyle 2002, p. 47; Bagnol and Mariano 2011, p. 281.
In 1979 the WHO held a seminar, "Traditional Practices Affecting the Health of Women and Children," in Khartoum, Sudan, and in 1981, also in Khartoum, the Babiker Badri Scientific Association for Women's Studies (BBSAWS) held a three-day workshop, "Female Circumcision Mutilates and Endangers Women – Combat it!" At the end of it 150 academics and activists signed a pledge to fight FGM. Another BBSAWS workshop in 1984 invited the international community to write a joint statement for the United Nations. Participants agreed that "female circumcision is a violation of human rights, an encroachment on the dignity of women, a debasement of women's sexuality, and an unwarranted affront on the health of women."Shahira Ahmed, "Babiker Badri Scientific Association for Women's Studies," in Abusharaf 2007, pp. 176–180. Their statement included:
*It was recommended that the goal of all African women should be the total eradication of female circumcision.
*[A]ll religious connotations in the practice, such as referring to clitoridectomy as "Sunna" ... should be abandoned. ...
*Substitute events and rituals should be devised ... This is now commonly referred to as the "alternative rite of passage."Ahmed 2007, p. 180.
The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, founded in 1984 in Dakar, Senegal, called for an end to the practice, as did the UN's World Conference on Human Rights in Vienna in 1993. The conference listed FGM as a form of violence against women, marking it as a violation of human rights, rather than a medical issue.Anika Rahman and Nahid Toubia, Female Genital Mutilation: A Guide to Laws and Policies Worldwide, New York: Zed Books, 2000, p. 10–11; for Vienna, UNICEF 2013 p. 8. Throughout the 1990s and 2000s African governments banned or restricted it. In July 2003 the African Union ratified the Maputo Protocol on the rights of women, which supported the elimination of FGM.Emma Bonino, "A brutal custom: Join forces to banish the mutilation of women", The New York Times, 15 September 2004; Maputo Protocol, pp. 7–8. By 2015 laws had been passed in at least 23 of the 27 African countries in which FGM is concentrated, although several fell short of a ban.For example, UNICEF 2013 lists Mauritania as having passed legislation against FGM, but (as of that year) it is banned only from being conducted in government facilities or by medical personnel. See UNICEF 2013, p. 8.
For the 22 countries, UNICEF 2013, pp. 8–9;UNICEF–UNFPA 2012 annual report, p. 12]. An asterisk indicates a ban:
Benin (2003), Burkina Faso (1996*), Central African Republic (1966, amended 1996), Chad (2003), Côte d'Ivoire (1998), Djibouti (1995, amended 2009*), Egypt (2008*), Eritrea (2007*), Ethiopia (2004*), Ghana (1994, amended 2007), Guinea (1965, amended 2000*), Guinea-Bissau (2011*), Kenya (2001, amended 2011*), Mauritania (2005), Niger (2003), Nigeria (2015*), Senegal (1999*), Somalia (2012*), Sudan, some states (2008–2009), Tanzania (1998), Togo (1998) and Uganda (2010*).Yemen and Iraq outlawed it, in 2001 and 2011 respectively, as did South Africa and Zambia, but the latter two are not among the countries in which it is concentrated.
===United Nations===
The United Nations General Assembly included FGM in resolution 48/104 in December 1993, the Declaration on the Elimination of Violence Against Women. In 2003 the UN began sponsoring an International Day of Zero Tolerance to Female Genital Mutilation every 6 February."48/104. Declaration on the Elimination of Violence against Women", United Nations General Assembly, 20 December 1993.
Charlotte Feldman-Jacobs, "Commemorating International Day of Zero Tolerance to Female Genital Mutilation", Population Reference Bureau, February 2009. UNICEF began that year to promote an evidence-based social norms approach to the evaluation of intervention, using ideas from game theory about how communities reach decisions, and building on the work of Gerry Mackie about how footbinding had ended in China.UNICEF 2013, p. 15; Francesca Moneti, David Parker, The Dynamics of Social Change, Florence: UNICEF Innocenti Research Centre, October 2010, p. 6. In 2005 the UNICEF Innocenti Research Centre in Florence published its first report on FGM.UNICEF 2013, p. 15; Michael Miller and Francesca Moneti, Changing a harmful social convention: Female genital cutting/mutilation, Florence: UNICEF Innocenti Research Centre, 2005.
In 2008 several United Nations bodies, including the Office of the High Commissioner for Human Rights, published a joint statement recognizing FGM as a human-rights violation.WHO 2008, p. 8; Yoder, Wang and Johansen, 2013, p. 190. In December 2012 the General Assembly passed resolution 67/146, calling for intensified efforts to eliminate it."67/146. Intensifying global efforts for the elimination of female genital mutilation", United Nations General Assembly, adopted 20 December 2012.
Emma Bonino, "Banning Female Genital Mutilation", The New York Times, 19 December 2012. In July 2014 UNICEF and the UK government co-hosted the first Girl Summit, aimed at ending FGM and child marriage."No time to lose: New UNICEF data show need for urgent action on female genital mutilation and child marriage", UNICEF, 22 July 2014; "Girl Summit", The Guardian.
UNFPA and UNICEF launched a joint programme in 2007 to reduce FGM by 40 percent within the 0–15 age group, and eliminate it entirely from at least one country. Fifteen countries joined the programme: Djibouti, Egypt, Ethiopia, Guinea, Guinea-Bissau, Kenya, Senegal and Sudan in 2008; Burkina Faso, Gambia, Uganda and Somalia in 2009; and Eritrea, Mali and Mauritania in 2011."UNFPA–UNICEF Joint Programme on Female Genital Mutilation/Cutting: Accelerating Change", Volume 1, 2008–2012, September 2013, p. viii. Phase 1 lasted from 2008 to 2013, with a budget of $37 million, over $20 million of it donated by Norway.2013 UNFPA-UNICEF Joint Programme evaluation, p. 38. Phase 2 extends the programme from 2014 to 2017."Joint Programme on the Abandonment of Female Genital Mutilation/Cutting. Funding Proposal for a Phase II", UNFPA–UNICEF, January 2014.
"Joint Programme on the Abandonment of Female Genital Mutilation/Cutting. Management Response and Key Actions", UNFPA–UNICEF, 19 February 2014.
By 2013 the programme had organized public declarations of abandonment in 12,753 communities, integrated FGM prevention into pre- and postnatal care in 5,571 health facilities, and trained over 100,000 doctors, nurses and midwives in FGM care and prevention. The programme helped to create alternative rites of passage in Uganda and Kenya, and in Sudan supported the (pre-existing) Saleema initiative. Saleema means "whole" in Arabic; the initiative promotes the term as a desirable description of an uncut woman.2013 UNFPA-UNICEF Joint Programme evaluation, pp. 4, 16–17; for alternative rites of passage and the Saleema initiative, pp. 22–23. The programme noted that anti-FGM law enforcement is weak, and that, even where arrests are made, prosecution may fail because of inadequate collection of evidence.UNFPA–UNICEF 2012, p. 48. It therefore supported the training of 3,011 personnel in eight countries (Djibouti, Eritrea, Ethiopia, Guinea, Guinea-Bissau, Kenya, Senegal and Uganda) in how to enforce the laws, and sponsored campaigns to raise awareness of them.UNFPA–UNICEF 2012, pp. 12–13.
===Non-practising countries===
====Overview====
 legislation banning FGM had been passed by 33 countries outside Africa and the Middle East.UNICEF 2013, p. 8. As a result of immigration the practice spread to Australia, New Zealand, Europe, North America and Scandinavia, all of which outlawed it entirely or restricted it to consenting adults.UNICEF 2005, p. 4: "Beyond economic factors, migratory patterns have frequently reflected links established in the colonial past. For instance, citizens from Benin, Chad, Guinea, Mali, Niger and Senegal have often chosen France as their destination, while many Kenyan, Nigerian and Ugandan citizens have migrated to the United Kingdom."In the 1970s, war, civil unrest and drought in a number of African states, including Eritrea, Ethiopia and Somalia, resulted in an influx of refugees to Western Europe, where some countries, such as Norway and Sweden, had been relatively unaffected by migration up to that point. Beyond Western Europe, Canada and the USA in North America, and Australia and New Zealand in Australasia also host women and children who have been subjected to FGM/C, and are home to others who are at risk of undergoing this procedure."Australia: "Review of Australia's Female Genital Mutilation Legal Framework", Attorney General's Department, Government of Australia.
New Zealand: "Section 204A – Female genital mutilation – Crimes Act 1961", New Zealand Parliamentary Counsel Office.
Europe: "Eliminating female genital mutilation", European Commission.
United States: "18 U.S. Code § 116 – Female genital mutilation", Legal Information Institute, Cornell University Law School.
Canada: Section 268, Criminal Code. Sweden outlawed it in 1982, the first Western country to do so.Birgitta Essén, Sara Johnsdotter, "Female Genital Mutilation in the West: Traditional Circumcision versus Genital Cosmetic Surgery", Acta Obstetricia Gynecologica Scandinavica, 83(7), July 2004 (pp. 611–613), p. 611. PMID 15225183 Several former colonial powers, including Belgium, Britain, France and the Netherlands, followed suit, either with new laws or by making clear that it was covered by existing legislation.Boyle 2002 p. 97.
====North America====
Canada recognized FGM as a form of persecution in July 1994, when it granted refugee status to Khadra Hassan Farah, who had fled Somalia to avoid her daughter being cut.Clyde H. Farnsworth, "Canada Gives Somali Mother Refugee Status", The New York Times, 21 July 1994. In 1997 section 268 of its Criminal Code was amended to make a ban on FGM explicit, except where "the person is at least eighteen years of age and there is no resulting bodily harm."Section 268, Criminal Code; UNICEF 2013, p. 8.
Also see Audrey Macklin, "The Double-Edged Sword: Using the Criminal Law Against Female Genital Mutilation," in Abusharaf 2007, p. 211ff; "Female Genital Cutting", Clinical practice guidelines, No. 299, The Society of Obstetricians and Gynaecologists of Canada, November 2013. there had been no prosecutions.Also see Mobina S. B. Jaffer, "Criminal Code, Bill to Amend – Second Reading, Debates of the Senate (Hansard), 1st Session, 41st Parliament, 148(79), 15 May 2012.
In the United States the Centers for Disease Control (CDC) estimated in 1997 that 168,000 women and girls living there in 1990 had undergone FGM or were at risk.Wanda K. Jones, et al., "Female Genital Mutilation/Female Circumcision: Who Is at Risk in the U.S.?", Public Health Reports, 112, September/October 1997 (pp. 368–377), p. 372. A preliminary, unpublished, CDC study in 2015 reportedly estimated that around 500,000 women and girls in the US had undergone FGM or were likely to undergo it.Julie Turkewitz, "Effects of Ancient Custom Present New Challenge to U.S. Doctors: Genital Cutting Cases Seen More as Immigration Rises", The New York Times, 6 February 2015.
Alexandra Topping, "FGM affects three times more people in the US than previously thought", The Guardian, 5 February 2015. A Nigerian woman successfully contested deportation in March 1994 on the grounds that her daughters might be cut,Patricia Dysart Rudloff, "In Re: Oluloro: Risk of female genital mutilation as 'extreme hardship' in immigration proceedings", 26 Saint Mary's Law Journal, 877, 1995. and in 1996 Fauziya Kasinga from Togo became the first to be granted asylum to escape FGM.Nussbaum 1999, pp. 118–119.
Celia W. Dugger, "June 9–15; Asylum From Mutilation",The New York Times, 16 June 1996.
"In re Fauziya KASINGA, file A73 476 695", U.S. Department of Justice, Executive Office for Immigration Review, decided 13 June 1996.
 several federal appellate courts have held that a parent cannot receive asylum based on a fear that their child will be subjected to FGM, particularly where the children are legal residents or citizens of the United States. See Alida Yvonne Lasker, "NOTE: Solomon's Choice: The Case for Granting Derivative Asylum to Parents," 32 Brooklyn Journal of International Law, 231, 2006.
In 1996 it became illegal under Title 18 of the United States Code, § 116, to perform FGM on minors for non-medical reasons,"§116. Female genital mutilation", U.S. Government Printing Office; "18 U.S. Code § 116 – Female genital mutilation", Legal Information Institute, Cornell University Law School.
"Legislation on Female Genital Mutilation in the United States", Center for Reproductive Rights, November 2004, p. 3.
Abusharaf 2007, p. 22.
Susan Deller Ross, Women's Human Rights: The International and Comparative Law Casebook, Philadelphia: University of Pennsylvania Press, 2008, pp. 509–511. and the National Defense Authorization Act for Fiscal Year 2013 prohibited transporting a minor out of the country for the purpose of FGM."Public Law 112–239 - Jan. 2, 2013 - National Defense Authorization Act for Fiscal Year 2013", 2 January 2013, Sec 1088, p. 340. The American Academy of Pediatrics opposes all forms of the practice. In 2010 it suggested that "pricking or incising the clitoral skin" was a harmless procedure that might satisfy parents, but withdrew the statement after complaints.Current policy: "Female Genital Mutilation", Pediatrics, 102(1), 1 July 1998, pp. 153–156. 
Withdrawn policy: "Ritual Genital Cutting of Female Minors", Pediatrics, 25(5), 1 May 2010, pp. 1088–1093. 
Pam Belluck, "Group Backs Ritual 'Nick' as Female Circumcision Option", The New York Times, 6 May 2010.
Susan Bewley, Sarah Creighton and Comfort Momoh, "Female genital mutilation: Paediatricians should resist its medicalisation", British Medical Journal, 340(7760), 19 June 2010, pp. 1317–1318. The first FGM conviction in the US was in 2006, when Khalid Adem, who had emigrated from Ethiopia, was sentenced to ten years after severing his two-year-old daughter's clitoris with a pair of scissors."Man gets 10-year sentence for circumcision of 2-year-old daughter", Associated Press, 1 November 2006.In 2014 President Barack Obama spoke about FGM for the first time, calling it "a tradition that's barbaric and should be eliminated"; see Nedra Pickler, "Obama To Rename Africa Young Leaders Program For Nelson Mandela", Huffington Post, 28 July 2014.
====Europe====
According to the European Parliament, 500,000 women in Europe had undergone FGM .Yoder, Wang and Johansen, 2013, p. 195. France is known for its tough stance against FGM, reflecting its position that French identity and unity depend on the assimilation of its immigrants. Up to 30,000 women there are thought to have experienced FGM. Colette Gallard, a family-planning counsellor, writes that when FGM was first encountered in France, the reaction was that Westerners ought not to intervene, and it took the deaths of two girls in 1982, one of them three months old, for that attitude to change.Colette Gallard, "Female genital mutilation in France", British Medical Journal, 310, 17 June 1995, p. 1592. 
That one girl was three months old, Megan Rowling "France reduces genital cutting with prevention, prosecutions – lawyer", Thomson Reuters Foundation, 27 September 2012.
The practice is outlawed by a provision of France's penal code dealing with violence against children.Megan Rowling "France reduces genital cutting with prevention, prosecutions – lawyer", Thomson Reuters Foundation, 27 September 2012. All children under six who were born in France undergo medical examinations that include inspection of the genitals, and doctors are obliged to report FGM. The first civil suit was in 1982 and the first criminal prosecution in 1993.For 1982, Gallard 1995, p. 1593; for 1993, Farnsworth (New York Times) 1994. In 1999 a woman was given an eight-year sentence for having performed FGM on 48 girls.David Gollaher, Circumcision: A History of the World's Most Controversial Surgery, New York: Basic Books, 2000, p. 189. By 2014 over 100 parents and two practitioners had been prosecuted in over 40 criminal cases.Renée Kool and Sohail Wahedi, "Criminal Enforcement in the Area of Female Genital Mutilation in France, England and the Netherlands: A Comparative Law Perspective", International Law Research, 3(1), 2014, pp. 3–5. 
Around 137,000 women and girls living in England and Wales in 2011 were born in countries where FGM is practised.Alison Macfarlane and Efua Dorkenoo, "Female Genital Mutilation in England and Wales", City University of London and Equality Now, 21 July 2014, p. 3.
"Female genital mutilation: the case for a national plan", House of Commons Home Affairs Committee, Second Report of Session 2014–15.
Also see "Female Genital Mutilation: Report of a Research Methodological Workshop on Estimating the Prevalence of FGM in England and Wales", Equality Now, 22–23 March 2012.
For an earlier report, Efua Dorkenoo, Linda Morison, Alison Macfarlane, "A Statistical Study to Estimate the Prevalence of Female Genital Mutilation in England and Wales", FORWARD, October 2007.
J. A. Black, G. D. Debelle, "Female genital mutilation in Britain", British Medical Journal, 310, 17 June 1995. Performing FGM on children or adults was outlawed under the Prohibition of Female Circumcision Act 1985.Kool and Wahedi 2014, pp. 5–7. This was replaced by the Female Genital Mutilation Act 2003 and Prohibition of Female Genital Mutilation (Scotland) Act 2005, which added a prohibition on arranging FGM outside the country for British citizens or permanent residents.Female Genital Mutilation Act 2003: "A person is guilty of an offence if he excises, infibulates or otherwise mutilates the whole or any part of a girl's labia majora, labia minora or clitoris," unless "necessary for her physical or mental health."
Although the legislation refers to girls, it applies to women too. See "Female Genital Mutilation Act 2003", legislation.gov.uk, and "Female Genital Mutilation Act 2003" (legal guidance), Crown Prosecution Service: "The Act refers to 'girls', though it also applies to women."
"Prohibition of Female Circumcision Act 1985", "Female Genital Mutilation Act 2003", "Prohibition of Female Genital Mutilation (Scotland) Act 2005", legislation.gov.uk. The United Nations Committee on the Elimination of Discrimination against Women asked the government in 2013 to "ensure the full implementation of its legislation on FGM.""Concluding observations on the seventh periodic report of the United Kingdom of Great Britain and Northern Ireland", United Nations Convention on the Elimination of All Forms of Discrimination against Women, 26 July 2013, p. 6, paras 36, 37. The first charges were brought the following year against a physician and another man, after the physician stitched an infibulated woman after opening her for childbirth. Both men were acquitted in 2015.Sandra Laville, "Doctor found not guilty of FGM on patient at London hospital", The Guardian, 4 February 2015.
==Criticism of opposition==
===Tolerance versus human rights===
Anthropologist Eric Silverman wrote in 2004 that FGM had "emerged as one of the central moral topics of contemporary anthropology." Anthropologists have accused FGM eradicationists of cultural colonialism; in turn, the former have been criticized for their moral relativism and failure to defend the idea of universal human rights.Silverman 2004, pp. 420 (for the quote), 427. According to the opposition's critics, the biological reductionism of the opposition, and the failure to appreciate the practice's cultural context, undermines the practitioners' agency and serves to "other" them – in particular by calling African parents mutilators.Vicky Kirby, "Out of Africa: 'Our Bodies Ourselves?'" in Obioma Nnaemeka (ed.), Female Circumcision and the Politics of Knowledge: African Women in Imperialist Discourses, Westport: Praeger, 2005, p. 83. Yet Africans who object to the opposition risk appearing to defend FGM.Obioma Nnaemeka, "African Women, Colonial Discourses, and Imperialist Interventions: Female Circumcision as Impetus," in Nnaemeka 2005, p. 33. Feminist theorist Obioma Nnaemeka – herself strongly opposed to FGM ("If one is circumcised, it is one too many") – argues that the impact of renaming it female genital mutilation cannot be underestimated:
In this name game, although the discussion is about African women, a subtext of barbaric African and Muslim cultures and the West's relevance (even indispensability) in purging the barbarism marks another era where colonialism and missionary zeal determined what "civilization" was, and figured out how and when to force it on people who did not ask for it.Nnaemeka 2005, pp. 34–35.
Ugandan law professor Sylvia Tamale argues that early Western opposition to FGM stemmed from a Judeo-Christian judgment that African sexual and family practices – including dry sex, polygyny, bride price and levirate marriage – were primitive and required correction.Tamale 2011, pp. 19–20. African feminists "do not condone the negative aspects of the practice", writes Tamale, but "take strong exception to the imperialist, racist and dehumanising infantilization of African women."
The debate has highlighted a tension between anthropology and feminism, with the former's focus on tolerance and the latter's on equal rights for all women. Anthropologist Christine Walley writes that a common trope within the anti-FGM literature has been to present African women as victims of false consciousness participating in their own oppression, a position promoted by several feminists in the 1970s and 1980s, including Fran Hosken, Mary Daly and Hanny Lightfoot-Klein. It prompted the French Association of Anthropologists to issue a statement in 1981, at the height of the early debates, that "a certain feminism resuscitates (today) the moralistic arrogance of yesterday's colonialism."Christine J. Walley, "Searching for 'Voices': Feminism, Anthropology, and the Global Over Female Genital Operations" in James and Robertson 2002, pp. 18, 34 (for false consciousness), 43.
For the statement, Bagnol and Mariano 2011, p. 281; for Hosken, Daly and Lightfoot-Klein, Robertson 2002, p. 60.
As an example of the disrespect arguably shown toward women who have undergone FGM, commentators highlight the appropriation of the women's bodies as exhibits. Historian Chima Korieh cites the publication in 1996 of the Pulitzer-prize-winning photographs of a 16-year-old Kenyan girl undergoing FGM. The photographs were published by 12 American newspapers, but according to Korieh the girl had not given permission for the images to be taken, much less published.Chima Korieh, Other' Bodies: Western Feminism, Race and Representation in Female Circumcision Discourse," in Nnaemeka 2005, pp. 121–122.
For the photographs, "Stephanie Welsh", 1996 Pulitzer Prize winners; for other examples, Nnaemeka 2005, pp. 30–33.
===Comparison with other procedures===
Obioma Nnaemeka argues that the crucial question, broader than FGM, is why the female body is subjected to so much "abuse and indignity" around the world, including in the West.Nnaemeka 2005, pp. 38–39. Several authors have drawn a parallel between FGM and cosmetic procedures.Sara Johnsdotter and Birgitta Essén, "Genitals and ethnicity: the politics of genital modifications", Reproductive Health Matters, 18(35), 2010 (pp. 29–37), p. 32. 
Samar A. Farage, "Female Genital Alteration: A Sociological Perspective," in Miranda A. Farage and Howard I. Maibach (eds.), The Vulva: Anatomy, Physiology, and Pathology, New York: Informa Healthcare USA, 2006, p. 267.
Marge Berer, "It's female genital mutilation and should be prosecuted", British Medical Journal, 334(7608), 30 June 2007, p. 1335. Ronán Conroy of the Royal College of Surgeons in Ireland wrote in 2006 that cosmetic genital procedures were "driving the advance of female genital mutilation" by encouraging women to see natural variations as defects.Ronán M. Conroy, "Female genital mutilation: whose problem, whose solution?", British Medical Journal, 333(7559), 15 July 2006. Anthropologist Fadwa El Guindi compares FGM to breast enhancement, in which the maternal function of the breast becomes secondary to men's sexual pleasure.El Guindi 2007, p. 33. Benoîte Groult made a similar point in 1975, citing FGM and cosmetic surgery as sexist and patriarchal.Lora Wildenthal, The Language of Human Rights in West Germany, Philadelphia: University of Pennsylvania Press, 2012, p. 148.
Carla Obermeyer maintains that FGM may be conducive to women's well-being within their communities in the same way that rhinoplasty and male circumcision may help people elsewhere.Obermeyer 1999, p. 94. In Egypt, despite the 2007 ban, women wanting FGM for their daughters discuss the need for amalyet tajmeel (cosmetic surgery) to remove what is viewed as excess genital tissue for a more acceptable appearance.Rahim (Tahrir Institute) 2014.
The WHO does not cite procedures such as labiaplasty and clitoral hood reduction as examples of FGM, but its definition aims to avoid loopholes, so several elective practices on adults do fall within its categories.WHO 2008, p. 28. Some of the laws banning FGM, including in Canada and the US, focus only on minors. Several countries, including Sweden and the UK, have banned it regardless of consent, and the legislation would seem to cover cosmetic procedures. Sweden, for example, has banned "[o]perations on the external female genital organs which are designed to mutilate them or produce other permanent changes in them ... regardless of whether consent to this operation has or has not been given."Johnsdotter and Essén 2010, p. 33. Gynaecologist Birgitta Essén and anthropologist Sara Johnsdotter note that it seems the law distinguishes between Western and African genitals, and deems only African women (such as those seeking reinfibulation after childbirth) unfit to make their own decisions.Johnsdotter and Essén 2010, p. 33; Essén and Johnsdotter 2004, p. 613.
Arguing against suggested similarities between FGM and dieting or body shaping, philosopher Martha Nussbaum writes that a key difference is that FGM is mostly conducted on children using physical force. She argues that the distinction between social pressure and physical force is morally and legally salient, comparable to the distinction between seduction and rape. She argues further that the literacy of women in practising countries is generally poorer than in developed nations, and that this reduces their ability to make informed choices.Nussbaum 1999, pp. 123–124.
Also see Yael Tamir, "Hands Off Clitoridectomy", Boston Review, Summer 1996.
Martha Nussbaum, "Double Moral Standards?", Boston Review, October/November 1996.
Several commentators maintain that children's rights are violated with the genital alteration of intersex children, who are born with anomalies that physicians choose to correct. Legal scholars Nancy Ehrenreich and Mark Barr write that thousands of these procedures take place every year in the United States, and say that they are medically unnecessary, more extensive than FGM, and have more serious physical and mental consequences. They attribute the silence of anti-FGM campaigners about intersex procedures to white privilege and a refusal to acknowledge that "similar unnecessary and harmful genital cutting occurs in their own backyards."Nancy Ehrenreich, Mark Barr, "Intersex Surgery, Female Genital Cutting, and the Selective Condemnation of 'Cultural Practices, Harvard Civil Rights-Civil Liberties Law Review, 40(1), 2005 (pp. 71–140), pp. 74–75.
Also see Cheryl Chase, Cultural Practice' or 'Reconstructive Surgery'? US Genital Cutting, the Intersex Movement, and Medical Double Standards," in James and Robertson (eds.) 2002, pp. 126–151.
==Notes==
==References==
==External links== 
*Female genital mutilation on Wikiquote
Category:Women and religion