Female genital cutting

Female genital cutting (FGC), also known as female genital mutilation (FGM), female circumcision, or female genital mutilation/cutting (FGM/C), is any procedure involving the partial or total removal of the external female genitalia or other injury to the female genital organs "whether for cultural, religious or other non-therapeutic reasons." The term is almost exclusively used to describe traditional or religious procedures on a minor, which requires the parents' consent because of the age of the girl.

When the procedure is performed on and with the consent of an adult it is generally called clitoridectomy, or it may be part of labiaplasty or vaginoplasty. It also generally does not refer to procedures used in sex reassignment surgery, and the genital modification of intersexuals.

FGC is practiced predominantly in North Africa and parts of the Middle East and Southeast Asia, although it has also been reported to occur in individual tribes in South America and Australia. Opposition is motivated by concerns regarding the consent (or lack thereof, in most cases) of the patient, and subsequently the safety and long-term consequences of the procedures. In the past several decades, there have been many concerted efforts by the World Health Organization (WHO) to end the practice of FGC. The United Nations has also declared February 6 as "International Day of Zero Tolerance to Female Genital Mutilation".

Varying terminology
Different terms are used to describe female genital surgery and other such procedures. The terms female genital mutilation (FGM) and female genital cutting (FGC) are now dominant in the international community. Practitioners commonly prefer the term female circumcision (FC). Groups that oppose the stigma of the word "mutilation" prefer to use the term female genital cutting. A few organizations have started using the combined term female genital mutilation/cutting (FGM/C). All terms are currently still actively used.

Female genital mutilation
Support for the term female genital mutilation grew in the late 1970s. The word "mutilation" not only established a clear linguistic distinction from male circumcision, but also emphasized the putative gravity of the act. In 1990 the term was adopted at the third conference of the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children (IAC) in Addis Ababa. In 1991, the World Health Organization (WHO) recommended that the UN adopt this terminology, which it did.

In this context, the term female genital mutilation has replaced the term female circumcision: "The extensive literature on the subject, the support of international organizations, and the emergence of local groups working against the continuation practices appear to suggest that an international consensus has been reached. The terminology used to refer to these surgeries has changed, and the clearly disapproving and powerfully evocative expression of 'female genital mutilation' has now all but replaced the possibly inaccurate, but less value-laden term of 'female circumcision'."

Female genital cutting
Because the term female genital mutilation has been criticized for increasing the stigma associated with female genital surgery, some groups have proposed an alteration, substituting the word "cutting" for "mutilation." According to a joint WHO/UNICEF/UNFPA statement, the use of the word "mutilation" reinforces the idea that this practice is a violation of the human rights of girls and women, and thereby helps promote national and international advocacy towards its abandonment. They state that, at the community level, however, the term can be problematic; and that local languages generally use the less judgmental "cutting" to describe the practice. They also state that parents resent the suggestion that they are "mutilating" their daughters. In 1999, the UN Special Rapporteur on Traditional Practices called for tact and patience regarding activities in this area and drew attention to the risk of "demonizing" certain cultures, religions, and communities. As a result, the term "cutting" has come to be used when trying to avoid alienating communities. In 1996, the Uganda-based initiative REACH (Reproductive, Educative, And Community Health) began using the term "FGC", observing that "FGM" may "imply excessive judgment by outsiders as well as insensitivity toward individuals who have undergone some form of genital excision." The UN uses "FGM" in official documents, while some of its agencies, such as the UN Population Fund, use both the terms "FGM" and "FGC".

Female circumcision
Several dictionaries, including medical dictionaries, define the word circumcision as applicable to some procedures performed on females. Cook states that historically, the term female circumcision was used, but that "this procedure in whatever form it is practiced is not at all analogous to male circumcision and so the term 'female circumcision' gave way to the term 'female genital mutilation'" Shell-Duncan states that the term female circumcision is a euphemism for a variety of procedures for altering the female genitalia. Toubia argued, in 1995, that the term female circumcision "implies a fallacious analogy to nonmutilating male circumcision, in which the foreskin is cut off from the tip of the penis without damaging the organ itself." However, in the 1999 book Male and Female Circumcision, Toubia states that she agrees that "circumcision — that is, the genital mutilation of girls and boys — is wrong despite its widespread practice."

Procedures: World Health Organization categorization
FGC consists of several distinct procedures. Their severity is often viewed as dependent on how much genital tissue is cut away. The WHO—which uses the term Female Genital Mutilation (FGM)—divides the procedure into four major types (see Diagram 1), although there is some debate as to whether all common forms of FGM fit into these four categories, as well as issues with the reliability of reported data.



Type I
The WHO defines Type I FGM as the partial or total removal of the clitoris (clitoridectomy) and/or the prepuce (clitoral hood); see Diagram 1B. When it is important to distinguish between the variations of Type I cutting, the following subdivisions are proposed: Type Ia, removal of the clitoral hood or prepuce only (which some view as analogous to male circumcision and thus more acceptable); Type Ib, removal of the clitoris with the prepuce. In the context of women who seek out labiaplasty, there is disagreement among doctors as to whether to remove the clitoral hood in some cases to enhance sexuality or whether this is too likely to lead to scarring and other problems.

Type II
The WHO's definition of Type II FGM is "partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. When it is important to distinguish between the major variations that have been documented, the following subdivisions are proposed: Type IIa, removal of the labia minora only; Type IIb, partial or total removal of the clitoris and the labia minora; Type IIc, partial or total removal of the clitoris, the labia minora and the labia majora.

Type III: Infibulation with excision
The WHO defines Type III FGM as narrowing of the vaginal orifice with creation of a covering seal by cutting and repositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation)." It is the most extensive form of FGM, and accounts for about 10% of all FGM procedures described from Africa.  Infibulation is also known as "pharaonic circumcision".

In a study of infibulation in the Horn of Africa, Pieters observed that the procedure involves extensive tissue removal of the external genitalia, including all of the labia minora and the inside of the labia majora. The labia majora are then held together using thorns or stitching. In some cases the girl's legs have been tied together for two to six weeks, to prevent her from moving and to allow the healing of the two sides of the vulva. Nothing remains but the walls of flesh from the pubis down to the anus, with the exception of an opening at the inferior portion of the vulva to allow urine and menstrual blood to pass through; see Diagram 1D. Generally, a practitioner recognized as having the necessary skill carries out this procedure, and a local anesthetic is used. However, when carried out "in the bush", infibulation is often performed by an elderly matron or midwife of the village, without sterile procedure or anesthesia.

A reverse infibulation can be performed to allow for sexual intercourse or when undergoing labor, or by female relatives, whose responsibility it is to inspect the wound every few weeks and open it some more if necessary. During childbirth, the enlargement is too small to allow vaginal delivery, and so the infibulation is opened completely and may be restored after delivery. Again, the legs are sometimes tied together to allow the wound to heal. When childbirth takes place in a hospital, the surgeons may preserve the infibulation by enlarging the vagina with deep episiotomies. Afterwards, the patient may insist that her vulva be closed again.

Women who have been infibulated face a lot of difficulty in delivering children, especially if the infibulation is not undone beforehand, which often results in severe tearing of the infibulated area, or fetal death if the birth canal is not cleared (Toubia, 1995). The risk of severe physical, and psychological complications is more highly associated with women who have undergone infibulations as opposed to one of the lesser forms of FGM. Although there is little research on the psychological side effects of FGM, many women feel great pressure to conform to the norms set out by their community, and suffer from anxiety and depression as a result (Toubia, 1995). "There is also a higher rate of post-traumatic stress disorder in circumcised females" (Nicoletti, 2007, p. 2).

A five-year study of 300 women and 100 men in Sudan found that "sexual desire, pleasure, and orgasm are experienced by the majority &#91;"nearly 90%"&#93; of women who have been subjected to this extreme sexual mutilation, in spite of their being culturally bound to hide these experiences."

Type IV: Other types
There are other forms of FGM, collectively referred to as Type IV, that may not involve tissue removal. The WHO defines Type IV FGM as "all other harmful procedures to the female genitalia for non-medical purposes, for example, pricking, piercing, incising, scraping and cauterization." This includes a diverse range of practices, such as pricking the clitoris with needles, burning or scarring the genitals as well as ripping or tearing of the vagina. Type IV is found primarily among isolated ethnic groups as well as in combination with other types.

Reasons for Female Genital Mutilation
Cultural, religious and social causes

The causes of female genital mutilation include a mix of cultural, religious and social factors within families and communities.


 * Where FGM is a social convention, the social pressure to conform to what others do and have been doing is a strong motivation to perpetuate the practice.


 * FGM is often considered a necessary part of raising a girl properly, and a way to prepare her for adulthood and marriage.


 * FGM is often motivated by beliefs about what is considered proper sexual behaviour, linking procedures to premarital virginity and marital fidelity. FGM is in many communities believed to reduce a woman's libido, and thereby is further believed to help her resist "illicit" sexual acts. When a vaginal opening is covered or narrowed (type 3 above), the fear of pain of opening it, and the fear that this will be found out, is expected to further discourage "illicit" sexual intercourse among women with this type of FGM.


 * FGM is associated with cultural ideals of femininity and modesty, which include the notion that girls are “clean” and "beautiful" after removal of body parts that are considered "male" or "unclean".


 * Though no religious scripts prescribe the practice, practitioners often believe the practice has religious support.


 * Religious leaders take varying positions with regard to FGM: some promote it, some consider it irrelevant to religion, and others contribute to its elimination.


 * Local structures of power and authority, such as community leaders, religious leaders, circumcisers, and even some medical personnel can contribute to upholding the practice.


 * In most societies, FGM is considered a cultural tradition, which is often used as an argument for its continuation.


 * In some societies, recent adoption of the practice is linked to copying the traditions of neighbouring groups. Sometimes it has started as part of a wider religious or traditional revival movement.


 * In some societies, FGM is being practised by new groups when they move into areas where the local population practice FGM.

Reversal
In recent years, surgical techniques to reverse FGM have been developed by gynecologists such as Dr. Pierre Foldes and Dr. Marci Bowers. Techniques can include ablating scar tissue, reconstructing the labia, and drawing the internal part of the clitoris outward to compensate for clitoral excision.

FGC can now be partially reversed via a surgical technique, which gives back certain sensation to the genitalia. Clitoraid, a non-profit international organization, is in the process of building a hospital in Burkina Faso, West Africa, where women who have undergone FGC will be able to receive this procedure free of charge. The hospital will be staffed with volunteers, including surgeons who specialise in the technique.

Cultural and religious aspects
A Greek papyrus from 163 B.C. mentions both boys and girls in Egypt undergoing circumcision and it is widely accepted to have originated in Egypt and the Nile valley at the time of the Pharaohs. Evidence from mummies has shown both Type I and Type III FGC present.

Al-Azhar Supreme Council of Islamic Research, the highest religious authority in Egypt, issued a statement saying FGM/C has no basis in core Islamic law or any of its partial provisions and that it is harmful and should not be practised."

Coptic Pope Shenouda, the leader of Egypt's minority Christian community, said that neither the Qur'an nor the Bible demand or mention female circumcision.

Medical consequence
Among practising cultures, FGC is most commonly performed between the ages of four and eight, but can take place at any age from infancy to adolescence. Prohibition has led to FGC going underground, at times with people who have had no medical training performing the cutting without anaesthetic, sterilisation, or the use of proper medical instruments. The procedure can lead to death through shock from excessive bleeding. The failure to use sterile medical instruments may lead to infections.

Other serious long term health effects are also common. These include urinary and reproductive tract infections, caused by obstructed flow of urine and menstrual blood, various forms of scarring and infertility. Epidermal inclusion cysts may form and expand, particularly in procedures affecting the clitoris. These cysts can grow over time and can become infected, requiring medical attention such as drainage. The first episode of sexual intercourse will often be extremely painful for infibulated women, who will need the labia majora to be opened, to allow their partner access to the vagina. This second cut, sometimes performed by the partner with a knife, can cause other complications to arise.

A June 2006 study by the WHO has cast doubt on the safety of genital cutting of any kind. This study was conducted on a cohort of 28,393 women attending delivery wards at 28 obstetric centers in areas of Burkina Faso, Ghana, Kenya, Senegal and The Sudan. A high proportion of these mothers had undergone FGC. According to the WHO criteria, all types of FGC were found to pose an increased risk of death to the baby (15% for Type I, 32% for Type II, and 55% for Type III). Mothers with FGC Type III were also found to be 30% more at risk for cesarean sections and had a 70% increase in postpartum haemorrhage compared to women without FGC. Estimating from these results, and doing a rough population estimate of mothers in Africa with FGC, an additional 10 to 20 per thousand babies in Africa die during delivery as a result of the mothers having undergone genital cutting.

In cases of repairing the damage resulting from FGC, called de-infibulation when reversing Type III FGC, this is usually carried out by a gynecologist. See also Pierre Foldes, a French surgeon, who developed modern surgical corrective techniques.

A 12-year-old Egyptian girl, Badour Shaker, died in June 2007 during or soon after a circumcision, prompting the Egyptian Health Ministry to ban the practice. She died from an overdose of anaesthesia. The girl's mother, Zeinab Abdel Ghani, paid the equivalent of US$9.00 (£4.60 pounds sterling, €6.82 euro) to a female doctor, in an illegal clinic in the southern town of Maghagh, for the operation. The mother stated that the doctor tried to give her $3,000 to withdraw a lawsuit, but she refused.

HIV
Relatively little research has been conducted on the effect female genital alteration may have on HIV prevalence. Some studies have found increased risk of HIV among women who had undergone FGC. Other studies have found no statistically significant associations,  or have identified more complex patterns. Two studies have reported that FGC is associated with decreased risk of HIV.

Kanki et al. (1992) reported that, in Senegalese prostitutes, women who had undergone FGC had a significantly decreased risk of HIV-2 infection when compared to those who had not. Klouman et al. (2005), studying women in Tanzania, found that among women who had undergone FGC the odds of being HIV positive were roughly twice those among women who had not. However, both HIV and FGC were strongly associated with age; when controlling for age, the association was no longer statistically significant.

Brewer et al. (2007) found that in virgins, FGC was associated with a higher prevalence of HIV infection (3.2% vs 1.4%), which the authors attributed to unsterile procedures. Among sexually experienced women, FGC was associated with lower HIV prevalence (5.5% vs 9.9%). The authors suggested two possible reasons: that an HIV-specific immunity might be acquired through FGC procedures, and mortality of those infected at the time of FGC would reduce HIV prevalence in surviving adults. Maslovskaya et al. (2009) found that FGC was associated with higher risk of HIV among women whose first-union partner was younger or the same-age, but it was associated with lower risk of HIV among women whose first-union partner was older than the women herself. Yount et al. reported that, although FGC and HIV were not directly related, FGC was indirectly related to HIV via a number of associations with other factors, including extra-union partners, early onset of sexual activity, being widowed or divorced, and having an older partner. The authors concluded that FGC "may be an early life-course event that indirectly alters women's odds of becoming infected with HIV through protective and harmful practices in adulthood".

Stallings et al. (2009) reported that, in Tanzanian women, the risk of HIV among women who had undergone FGC was roughly half that of women who had not; the association remained significant after adjusting for region, household wealth, age, lifetime partners, union status, and recent ulcer. The authors, who expressed surprise at their finding, concluded that the association was due to confounding due to a further, unknown factor.

Recent reviews have suggested that FGC may increase the risk of HIV. Several mechanisms have been proposed by which FGC would expose women to greater risk of HIV. These include: non-sterile procedures (Monjok notes that the same instrument is frequently used on 15–20 girls); an increase in blood transfusions due to blood loss during the procedure itself, intercourse, or childbirth; increased anal intercourse due to difficult or painful vaginal intercourse; tearing of the vagina during intercourse; and increased susceptibility to infectious conditions that are recognised risk factors for HIV, such as genital ulcers.

Sexual effects
The effect of FGC on a woman's sexual experience varies depending on many factors. FGC does not eliminate all sexual pleasure for all women who undergo the procedure, but it does reduce the likelihood of orgasm. Stimulation of the clitoris is not solely responsible for the sexual excitement and arousal of a woman during intercourse; this involves a complex series of nerve endings being activated and stimulated in and around her vagina, vulva (labia minora and majora), cervix, uterus and clitoris, with psychological response and mindset also playing a role.

Lightfoot-Klein (1989) studied circumcised and infibulated females in Sudan, stating, "Contrary to expectations, nearly 90% of all women interviewed said that they experienced orgasm (climax) or had at various periods of their marriage experienced it. Frequency ranged from always to rarely." Lightfoot-Klein stated that the quality of orgasm varied from intense and prolonged, to weak or difficult to achieve.

A study in 2006 found that in some infibulated women, some erectile tissue fundamental to producing pleasure had not been completely excised. Defibulation of subjects revealed that a part of or the whole of the clitoris was underneath the scar of infibulation. The study found that sexual pleasure and orgasm are still possible after infibulation, and that they rely heavily on cultural influences — when mutilation is lived as a positive experience, orgasm is more likely. When FGC is experienced as traumatic, its frequency drops. The study suggested that FGC women who did not suffer from long-term health consequences and are in a good and fulfilling relationship may enjoy sex, and women who suffered from sexual dysfunction as a result of FGC have a right to sex therapy.

Psychological and psychiatric consequences
In February 2010, a study by Pharos, a Dutch group which gathers information on health care for refugees and migrants, found that many women who have undergone FGC suffer psychiatric problems. This was the first study into the psychiatric and social complaints associated with female circumcision. In the study 66 questioned Dutch African women, who had been subjected to the practice, were found to be "stressed, anxious and aggressive". It also found that they were more likely to have relational problems or in some cases had fears of establishing a relationship. According to the study, an estimated 50 women or girls are believed to be circumcised every year in the Netherlands. The report was published to mark the International day against female genital mutilation.

A study by Anthropologist Rogaia M. Abusharaf, found that "circumcision is seen as 'the machinery which liberates the female body from its masculine properties' and for the women she interviewed, it is a source of empowerment and strength".

Attempts to end the practice
Despite laws forbidding the practice, FGC remains an enduring tradition in many societies and cultural groups. Political leaders have found FGC difficult to eliminate on the local level because of its cultural and sometimes political importance. For instance, in Kenya, missionaries present in the 1920s and 1930s forbade their Christianised adherents to practice clitoridectomy. In response, FGC became instrumental to the ethnic independence movement among the Kikuyu, the most populous ethnic group of Kenya – indigenous people reacted against what they perceived as cultural imperialistic attacks by Europeans. Likewise, prohibition by the British of the procedure among tribes in Kenya significantly strengthened the tribes' resistance to British colonial rule in the 1950s and increased support for the Mau Mau guerrilla movement.

Because the practice holds much cultural and marital significance, FGC opponents recognize that ending it requires that they work closely with local communities. To leave no individuals handicapped, as happened with the rapid abandonment of foot binding among the Chinese early in the 20th century, members of a marriage network must all give up the practice simultaneously.

Despite the close tie between FGC and cultural and, sometimes, religious tradition, there are cases where attempts at ending FGC have been successful. One example is in Senegal, where initiative was taken by native women working at the local level in connection with the NGO Tostan. Since 1997, 4,203 communities in Senegal, 364 in Guinea, 23 in Burkina Faso, 24 in The Gambia, and 14 in Somalia have voluntarily given up FGC and are also working to end early and forced marriage. This has come about through the voluntary efforts of locals carrying the message out to other villages within their marriage networks in a self-replicating process. The expansion of community declarations, beginning in the village of Malicounda Bambara in 1997 and continuing to grow, "show the replicability of the Tostan program for large-scale abandonment of this practice". Molly Melching, founder of Tostan, and UNICEF believe that in Senegal the practice of female genital mutilation could be ended by 2015. She credits education, instead of cultural imperialism, for the rapid and significant changes in Senegal.

Some countries that prohibited FGC still experience the practice in secrecy. In many cases, enforcement of this prohibition is a low priority for governments. Other countries have tried to educate practitioners to make it easier and safer instead of outlawing the practice entirely. However, with pressure from the WHO and other groups, laws are being passed in regards to FGC. On June 28, 2007 Egypt banned female genital cutting after the death of 12-year-old Badour Shaker during a genital circumcision. The Guardian of Britain reported that her death "sparked widespread condemnation" of the practice. However, Britain has had its own problem confronting cases of FGC, as immigrants from Africa have been known to send their daughters to their home nations to undergo the procedure before returning to Britain.

In Mauritania, where "health campaigners estimate that more than 70 percent of Mauritanian girls undergo the partial or total removal of their external genitalia for non-medical reasons", 34 Islamic scholars signed a fatwa banning the practice in January 2010. Their aim was to prevent people from citing religion as a justification for genital mutilation.

The United Nations Population Fund (UNFPA) has declared February 6 as the International Day Against Female Genital Mutilation. The UNFPA has stated that "[the] practice violates the basic rights of women and girls" and "female genital mutilation or cutting is not required by any religion."

There are two main anti-FGC frameworks: the health model and the human rights-based model. The health model campaign defines FGC as harmful to women's health (physical and psychological trauma, sterility, damage to the urethra and anus, tetanus, child and maternal mortality and more recently HPV and HIV infection). This approach has failed to bring about large scale behavioural change. And although the health model is against FGC and the adverse effects associated, they often reject methods to provide medical support to minimize FGC health risks (i.e. medicalization). The human rights-based model has in more recent times replaced the health based model as the preferred approach in anti-FGC campaigns. The human rights model encompasses four important human rights discourses: violence against women, rights of the child, freedom from torture and rights to health and bodily integrity.

Laws and prevalence
Amnesty International estimates that 135 million women worldwide have experienced some form of FGM, with over 2 million girls estimated to undergo the procedure every year. Female circumcision is a pre-marital custom mainly endemic to Northeast Africa (see Map) and parts of the Near East that has its ultimate origins in Ancient Egypt. Encouraged by women in the community, it is primarily intended to deter promiscuity and to offer protection from assault. In 2007, Egypt passed a law completely banning FGM.

Whilst FGM is widely practised out in the open by many communities of varied faiths in its locus of concentration in Northeastern Africa, it is practised in secrecy in some parts of the Middle East. In the Arabian peninsula, Types I and II FGM are usually performed, often referred to as Sunna circumcision. The practice occurs particularly in northern Saudi Arabia, southern Jordan, and northern Iraq (Kurdistan). In the Iraqi village of Hasira, a recent study found that 60 percent of the women and girls reported having undergone FGM. Before the study, there had been no solid proof of the prevalence of the practice. There is also circumstantial evidence to suggest that FGM is practised in the Kurdish regions of Syria, Turkey and Iran. In Oman, a few communities still practice FGM; however, experts believe that the number of such cases is small and declining annually. In the United Arab Emirates and Saudi Arabia, it is practiced mainly among foreign workers from East Africa and the Nile Valley. A 2009 study suggested that FGM had virtually disappeared among the Negev Bedouin due to modernisation process under Israeli rule.

The practice can also be found among a few ethnic groups in South America. In Indonesia, the practice is common in several districts; almost all are Type I or Type IV, the latter usually involving the pricking of blood release. Sometimes the procedures are merely symbolic, and no actual cutting is done.

As a result of immigration, the practice has also spread to Europe, Australia and the United States. Some tradition-minded families have their daughters undergo FGM whilst on vacation in their home countries. As Western governments become more aware of FGM, legislation has come into effect in many countries to make the practice of FGM a criminal offense. In 2006, Khalid Adem became the first man in the United States to be prosecuted for circumcising his daughter.

A lot of sources exist for the practice, but all sources point into different directions. The practice can not be attributed to just one ethnic group and may not be trivialised in these regions. Even if a country officially forbids or denies the practice, it is often a traditional part in the sociological structure. It is hard to get such behaviour out of the line of generations because it belongs to the traditional practices or religion. FGM is often justified by Freedom of Religion because it is seen as a religious practice.

Africa
In July, 2003 at its second summit, the African Union adopted the Maputo Protocol promoting women's rights including and to end female genital mutilation. Having been ratified by fifteen members, it went into force in November, 2005. By December 2008, 25 member countries had ratified and deposited the Maputo Protocol.

The countries where FGC is commonly practised were identified by the US State Department. Other information in this section is from Skaine (2005), Appendix I.


 * Burkina Faso (71.6% prevalence, Type II): A law prohibiting FGC was enacted in 1996 and went into effect in February 1997. Even before this law, however, a presidential decree had set up the National Committee against excision and imposed fines on people guilty of excising girls and women. The new law includes stricter punishment. Several women excising girls have been handed prison sentences. Burkina Faso ratified the Maputo Protocol in 2006.


 * Central African Republic (43.4% prevalence, Type I and II): In 1996, the President issued an Ordinance prohibiting FGC throughout the country. It has the force of national law. Any violation of the Ordinance is punishable by imprisonment of from one month and one day to two years and a fine of 5,100 to 100,000 francs (approximately US$8–160). No arrests are known to have been made under the law.


 * Chad (60% prevalence, Type II and III): In 2001 law was being drafted to specifically outlaw FGC. Prior to this it may have been prosecutable under existing laws protecting minors from involuntary physical assault.


 * Côte d'Ivoire (44.5% prevalence, Type II): A December 18, 1998 law provides that harm to the integrity of the genital organ of a woman by complete or partial removal, excision, desensitization or by any other procedure will, if harmful to a women's health, be punishable by imprisonment of one to five years and a fine of 360,000 to two million CFA Francs (approximately US$576–3,200). The penalty is five to twenty years incarceration if a death occurs during the procedure and up to five years' prohibition of medical practice, if this procedure is carried out by a doctor.


 * Djibouti (90–98% prevalence, Type II and III): FGC was outlawed in the country's revised Penal Code that went into effect in April 1995. Article 333 of the Penal Code provides that persons found guilty of this practice will face a five year prison term and a fine of one million Djibouti francs (approximately US$5,600). Djibouti ratified the Maputo Protocol in 2005.


 * Egypt (78–97% prevalence, Type I, II and III): Egypt's Ministry of Health and Population has banned all forms of female genital cutting since 2007. The ministry's order declared it is 'prohibited for any doctors, nurses, or any other person to carry out any cut of, flattening or modification of any natural part of the female reproductive system'. Islamic authorities in the nation also stressed that Islam opposes female circumcision. The Grand Mufti of Egypt, Ali Gomaa, said that it is "Prohibited, prohibited, prohibited." The June 2007 Ministry ban eliminated a loophole that allowed girls to undergo the procedure for health reasons. There had previously been provisions under the Penal Code involving "wounding" and "intentional infliction of harm leading to death", as well as a ministerial decree prohibiting FGC. In December 1997, the Court of Cassation (Egypt's highest appeals court) upheld a government banning of the practice providing that those who did not comply would be subjected to criminal and administrative punishments. This law had proved ineffective and in a survey in 2000, a study found that 97% of the country's population still practiced FGC. In light of the widespread practice of FGC, even after the ban in 1997, some Egyptian villages decided to voluntarily give up the practice, as was the case with Abou Shawareb, which vowed in July 2005 to end the practice. However, it remains a culturally accepted practice, and a 2005 study found that over 95% of Egyptian women have undergone some form of FGC.


 * Eritrea (90% prevalence, Type I, II, and III): Eritrea has outlawed all forms of female genital cutting since 2007.


 * Ethiopia (69.7%–94.5% prevalence, Type I, II, III, and IV): Ethiopia's Regional statistics of the prevalence from the survey are: Afar Region – 94.5 percent; Harare Region – 81.2 percent; Amhara Region – 81.1 percent; Oromia Region – 79.6 percent; Addis Ababa City – 70.2 percent; Somali Region – 69.7 percent; Beneshangul Gumuz Region – 52.9 percent; Tigray Region – 48.1 percent; Southern Region – 46.3 percent. This practice is not specifically illegal in Ethiopia. Discussions with government officials and NGOs active in the eradication of these practices indicate that the legal provision for prohibiting harmful traditional practices and the policy statements against them are not, as a practical matter, enforced. There are no documented cases of women going to court over or seeking protection against this practice. We are unaware of any groups or organizations that provide protection to women or girls who wish to avoid it.


 * Ghana (9–15% prevalence, Type I,II and III): In 1989, the head of the government of Ghana, President Rawlings, issued a formal declaration against FGC. Article 39 of Ghana's Constitution also provides in part that traditional practices that are injurious to a person's health and well being are abolished. Ghana ratified the Maputo Protocol in 2007.


 * Guinea (98.6% prevalence, Type I, II and III): FGC is illegal in Guinea under Article 265 of the Penal Code. The punishment is hard labor for life and if death results within 40 days after the crime, the perpetrator will be sentenced to death. No cases regarding the practice under the law have ever been brought to trial. Article 6 of the Guinean Constitution, which outlaws cruel and inhumane treatment, could be interpreted to include these practices, should a case be brought to the Supreme Court. A member of the Guinean Supreme Court is working with a local NGO on inserting a clause into the Guinean Constitution specifically prohibiting these practices. Guinea signed the Maputo Protocol in 2003 but has not ratified it.


 * Nigeria (25.1% prevalence, Type I, II and III): There is no federal law banning the practice of FGC in Nigeria. Opponents of these practices rely on Section 34(1)(a) of the 1999 Constitution of the Federal Republic of Nigeria that states "no person shall be subjected to torture or inhuman or degrading treatment" as the basis for banning the practice nationwide. A member of the House of Representatives has drafted a bill, not yet in committee, to outlaw this practice. Nigeria ratified the Maputo Protocol in 2005.


 * Senegal (5–20% prevalence, Type II and III): A law that was passed in January 1999 makes FGC illegal in Senegal. President Diouf had appealed for an end to this practice and for legislation outlawing it. The law modifies the Penal Code to make this practice a criminal act, punishable by a sentence of one to five years in prison. A spokesperson for the human rights group RADDHO (The African Assembly for the Defense of Human Rights) noted in the local press that "Adopting the law is not the end, as it will still need to be effectively enforced for women to benefit from it. Senegal ratified the Maputo Protocol in 2005.


 * Somalia (95 % prevalence, Type I and III): In 1999 Parliament approved legislation making FGM illegal although there is little evidence to support its enforcement.


 * Sudan (91% prevalence, Type I, II and III): Currently there is no law forbidding FGC, although Sudan was the first country to outlaw it in 1946, under the British. Type III was prohibited under the 1925 Penal Code, with less severe forms allowed. Outreach groups have been trying to eradicate the practice for 50 years, working with NGOs, religious groups, the government, the media and medical practitioners. Arrests have been made but no further action seems to have taken place. Sudan signed the Maputo Protocol in June, 2008 but no ratification has yet been deposited with the African Union.


 * Tanzania (17.6% prevalence, Type II and III): Section 169A of the Sexual Offences Special Provisions Act of 1998 prohibits FGC. Punishment is imprisonment of from five to fifteen years or a fine not exceeding 300,000 shillings (approximately US$250) or both. There have been some arrests under this legislation, but no reports of prosecutions yet. Tanzania ratified the Maputo Protocol in 2007.


 * Togo (12% prevalence, Type II): On October 30, 1998, the National Assembly unanimously voted to outlaw the practice of FGC. Penalties under the law can include a prison term of two months to ten years and a fine of 100,000 francs to one million francs (approximately US$160 to 1,600). A person who had knowledge that the procedure was going to take place and failed to inform public authorities can be punished with one month to one year imprisonment or a fine of from 20,000 to 500,000 francs (approximately US$32 to 800). Togo ratified the Maputo Protocol in 2005.


 * Uganda (<5% prevalence, Type I and II): Recently, a law was passed to outlaw genital mutilation. Under this law, anyone convicted of this practice is subject to 10 years in prison. If the life of the patient is lost during the operation a life sentence is recommended. In 1996, however, a court intervened to prevent the performance of this procedure under Section 8 of the Children Statute, enacted that year, that makes it unlawful to subject a child to social or customary practices that are harmful to the child's health. Uganda signed the Maputo Protocol in 2003 but has not ratified it, despite calls from women's rights advocates. In early July 2009, President Yoweri Museveni stated that a law would soon be passed prohibiting the practice, with alternative livelihoods found for its practitioners.

Southeast Asia

 * Indonesia (No national prevalence figures avail., Type I and IV): In 2006 FGC was banned by the government. However, since the ban the practice has undergone a resurgence, primarily due to promotion by religious groups such as Indonesian Ulema Council.


 * Malaysia (No national prevalence figures avail., Type IV): No laws exist in reference to FGC, although the practice is reported in certain regions.

Middle East

 * Iran (No national prevalence figures avail.): The practice exists in Western and Southern Iran, primarily in Iranian Kurdistan where it is reported to be widespread, but also in regions such as Khuzestan.


 * Iraq, Iraqi Kurdistan (72.7% prevalence (excluding Dohuk), Type I and II ): There is no law against FGM in Iraqi Kurdistan, but in 2007 a draft legislation condemning the practice was submitted to the Regional Parliament, but was not passed.


 * Jordan (No national prevalence figures avail.): The practice is prevalent in Jordan.


 * Saudi-Arabia (No national prevalence figures avail.): The practice is prevalent in Northern Saudi-Arabia.


 * Syria (No national prevalence figures avail.): Circumstantial evidence suggests the practice exists in Syria.


 * Turkey (No national prevalence figures avail.): Circumstantial evidence suggests the practice exists in Turkey.


 * United Arab Emirates(No national prevalence figures avail., Type I ): The WHO mentions a study that documents FGC in UAE, but does not provide data. A report at a conference in 2003 of the findings by the authors suggest that the practice is prevalent in rural and urban UAE, but is declining.


 * Yemen (23% prevalence in women 15 to 49 ): In addition to the adult prevalence, UNICEF reports that 20% of women aged 15-49 have a daughter who had the procedure.

Other regions
Several countries outside areas where FGC is traditionally performed have laws banning the practice.


 * Australia: In 1994 there were several anecdotal reports of FGC being practised amongst migrant communities in Australia. By 1997, all Australian states and territories had made FGC a specific criminal offence. It is also a criminal offence to take, or propose to take, a child outside Australia to have a FGC procedure performed. The incidence of FGC in Australia is unknown as it is unreported to authorities and is often only uncovered when women and girls are taken to hospital due to complications with the procedure.


 * Canada: FGC is considered child assault and prohibited under sections 267 (assault causing bodily harm) or 268 (aggravated assault, including wounding, maiming, disfiguring) of the Criminal Code.


 * France: FGC, like other forms of sexual mutilation, is a criminal offense punishable by up to 20 years in jail. In addition, the law requires anyone to report any case of mutilation or planned mutilation. This means that adults who send girls abroad to be excised can be pursued criminally in France.


 * Italy: After a few cases of infibulation practised by complaisant medical practitioners within the African immigrants community came to public knowledge through Media coverage, the Law n°7/2006 was passed on 1/9/2006, becoming effective on 1/28/2006, concerning "Measures of prevention and prohibition of any female genital mutilation practice"; the Act is also known as the Legge Consolo ("Consolo Act") named after its primary promoter, Senator Giuseppe Consolo. Article 6 of the law integrates the Italian Penal Code with Articles 583-Bis and 583-Ter, punishing any practice of female genital cutting and/or mutilation "not justifiable under therapeutical or medical needs" with imprisonment ranging from 4 to 12 years (3 to 7 years for any mutilation other than, or less severe than, clitoridectomy, excision or infibulation). Penalty can be reduced up to $2/3$ if the harm caused is of modest entity (i.e. if partially or completely unsuccessful), but may also be elevated up to $1/undefined$ if the victim is a minor or if the offense has been committed for profit. An Italian citizen or a foreign citizen legally resident in Italy can be punished under this law even if the offence is committed abroad; the law will as well afflict any individual of any citizenship in Italy, even illegally or provisionally. The law also mandates any medical practitioner found guilty under those provisions to have his/her medical licence revoked for a minimum of six up to a maximum of ten years. The law gained general public consense, and continues to receive nowadays support from several women's rights movements. Supporters of the law however input that more could yet be done to protect young girls within the communities of African immigrants from such practices, as it is reported that "the girls go on vacation in their families' homelands to visit their grandparents and return infibulated".


 * Norway: FGC is punishable as a criminal offence under Norwegian law even if the offence is committed abroad.


 * Netherlands: FGC is considered mutilation and is punishable as a criminal offence under Dutch law. There is no specific law against FGC: the act is subsumed under the general offence of inflicting harm ("mishandeling", art. 300–304 Dutch Criminal Code). The maximum penalty is a prison sentence of 12 years. However, the sentence can be higher if the offender is a family member of the victim. It is also illegal to assist or encourage another person to perform FGC. A Dutch citizen or a foreign citizen legally resident in the Netherlands can be punished even if the offence is committed abroad. Doctors have the obligation to report suspected cases of FGC and may break patient confidentiality rules if necessary.


 * New Zealand: Under a 1995 amendment to the Crimes Act, it is illegal to perform "any medical or surgical procedure or mutilation of the vagina or clitoris of any person" for reasons of "culture, religion, custom or practice". It is also illegal to send or make any arrangement for a child to be sent out of New Zealand for FGC to be performed, assist or encourage any person in New Zealand to perform FGC on a New Zealand citizen or resident outside New Zealand convince or encourage any other New Zealand citizen or resident to go outside New Zealand to have FGC performed.


 * Sweden: FGC is punishable according to Act (1982:316) Prohibiting Female Genital Mutilation. Sweden was the first Western country to prohibit FGC, legislation against 'female circumcision' passed in 1982. In 1998 the law was revised with a change in terminology and more severe penalties for breaking the law were imposed. The law was further reformulated in 1999, to allow for prosecution in a Swedish court of someone performing FGC even if the act has been performed in a country where it is not considered criminal (removal of the principle of double incrimination).


 * United Kingdom: FGC was made a specific criminal offence by the Prohibition of Female Circumcision Act 1985. A girl could be removed from her home, if this was the only way that her protection could be guaranteed. This was superseded by the Female Genital Mutilation Act 2003, and (in Scotland) by the Prohibition of Female Genital Mutilation (Scotland) Act 2005. In addition to FGC within the UK, taking a UK citizen or permanent resident abroad for the purpose of FGC is a criminal offence whether or not it is lawful in the country that the girl is taken to.


 * United States: Federal law prohibiting FGC was enacted in 1996. Seventeen states enacted similar laws between 1994 and 2006.

Literature

 * Desert Flower by Waris Dirie (1999): Waris Dirie's autobiographical novel, which tells the story of her own childhood and genital mutilation, was written in collaboration with Cathleen Miller. The book has been printed in numerous languages and topped bestseller lists in Europe.
 * Do They Hear You When You Cry by Fauziya Kassindja (1999): Fauziya Kassindja's story of fleeing Africa just hours before the ritual kakia takes place, and seeking asylum in America resulting in her 16 months behind bars. Ultimately, in a landmark decision in immigration history, Fauziya Kassindja was granted asylum on June 13, 1996.
 * Desert Dawn by Waris Dirie (2003): The book describes how Dirie became a UN Special Ambassador against female genital mutilation (FGM) and returned to her family in Somalia. Written in collaboration with Jeanne D'Haem.
 * Desert Children reveals how Dirie and journalist Corinna Milborn investigated the practice of FGC in Europe. Waris reports on encounters with circumcised women and circumcisers, on the difficult research, on setbacks and achievements. Written with Corinna Milborn, translation by Sheelagh Alabaster; published in 2007 by Time Warner UK. A Europe-wide campaign against Female Genital Mutilation (FGM) was initiated after the publication of this book.
 * Possessing the Secret of Joy by Alice Walker (1993): Novel that explores the themes of violence, sexism, misogyny, and female genital mutilation in African, British, and American society.
 * No Laughter Here by Rita Williams-Garcia (2004): Novel that explores the effects of a ten year old Nigerian girl who got FGC while on vacation in her homeland and her best friend's struggle to understand what has happened to her friend.
 * Sweetness in the Belly by Camilla Gibb (2005): Novel about a white Muslim woman named Lilly living in Harar. FGC is performed on the two daughters of the woman Lilly stays with.
 * Up the Walls of the World (1976) by James Tiptree, Jr ( a pseudonym for writer Alice Sheldon )  : The protagonist, Margaret Omali, suffers FGC as a Kenyan-American child at the hands of her father.
 * Infidel: My Life by Ayaan Hirsi Ali (2007): The author, Ayaan, is "exorcised", including having her labia stitched together as a young girl under the guidance of her grandmother.

Films

 * IMDB list of best "Female Genital Mutilation" Titles
 * IMDB list of best "Female Circumcision" Titles
 * Finzan by Cheick Oumar Sissoko (1989, Mali): About two women who rebel against the traditions of a village society.
 * Bintou in Paris by Kirsten Johnson and Julia Pimsleur (1995 documentary short, France)
 * Schnitt ins Leben – Afrikanerinnen bekämpfen ein Ritual by Dagmar Brendecke and Anke Müller-Belecke (2000 TV documentary, Germany)
 * The Day I Will Never Forget by Kim Longinotto (2002 documentary, UK)
 * Dabla! Excision by Erica Pomerance (2003 documentary, Canada): Follows the growing movement across Africa to stop FGC.
 * Moolaadé by Ousmane Sembène (2004, Senegal, France, Burkina Faso, Cameroon, Morocco, Tunisia)
 * Dunia by Jocelyn Saab (2005 Drama, Egypt-Lebanon-France)
 * Kokonainen by Alexis Kouros (2005 short, Finland): The film won 2005 New York Short Film Festival Jury Award for Best Screenplay.
 * God's Sandbox by Doron Eran (2006, Israel) An Israeli girl joins a Muslim tribe and is forced to undergo FGC.
 * Maimouna – La vie devant moi by Fabiola Maldonado (2007 documentary, Germany)
 * Desert Flower – The Feature Film Directed by Sherry Horman (is to be released in autumn 2009) based on Waris Dirie's first book, Desert Flower.
 * Antichrist by Lars von Trier (released in 2009) : graphic auto-clitoridectomy scene
 * L'appel de Diégoune / Diégoune Call to Action: Walking the Path of Unity (2009) by Marc Dacosse and Eric Dagostino for Tostan, Tostan France, Respect, Diégoune

Print

 * Aldeeb, Sami (2000). Male and Female Circumcision in the Jewish, Christian and Muslim Communities, Religious debate. Beirut, ISBN 1-85513-406-3.
 * Dirie, Waris (2001). Desert Flower. Autobiography of a Somali woman's journey from nomadic tribal life to a career as a fashion model in London and to the post of special ambassador at the United Nations. Dirie recounts her personal experience with female genital mutilation that began with circumcision at age five.
 * Leonard, Lori (2000). We did it for pleasure only: Hearing alternative tales of female circumcision. Qualitative Inquiry, 6(2), 212–228.
 * Mernissi, Fatima. Beyond the veil: Male-female dynamics in a modern Muslim society. Cambridge, Massachusetts: Schenkman Pub. Co. ISBN 0-470-59613-9.
 * Mustafa, Asim Zaki (1966). Female circumcision and infibulation in the Sudan. Journal of Obstetrics and Gynaecology of the British Commonwealth, 73(2), 302–306..
 * Robinett, Patricia (2006). The rape of innocence: One woman's story of female genital mutilation in the USA. N.p.: Aesculapius Press. ISBN 1-878411-04-7.
 * Siddique Saqafi Sidheeqi (2009), Female Circumcision in Islam, Retrieved from www.islamxplored.com.
 * Robinett, Patricia (2006). The rape of innocence: One woman's story of female genital mutilation in the USA. N.p.: Aesculapius Press. ISBN 1-878411-04-7.
 * Siddique Saqafi Sidheeqi (2009), Female Circumcision in Islam, Retrieved from www.islamxplored.com.