Female Genital Mutilation: Definition, How it Works, Types, and Facts

Female Genital Mutilation 

Female genital mutilation (FGM) or female circumcision means the complete or partial removal of the female external genitalia resulting in injury and damage without any medical reason. FGM is mostly performed on young girls and women below 15. It is traditionally performed in some countries in Africa and the Middle East and is illegal in most countries, including the United Kingdom. FGM is considered a gross violation of the fundamental human and reproductive rights of women and girls, severely compromising their dignity, security and health. The World Health Organisation (WHO) categorises it into four types with different procedures and complications. The four types are type 1, or clitoridectomy, which involves complete or partial removal of the clitoris; type 2 or excision, in which both the clitoris and inner folds of the vulva (labia minora) are removed, and sometimes it involves the removal of labia majora or the larger outer lips; type 3, also known as infibulation, in which the opening of the vagina is narrowed down by creating a covering seal by the cutting, and subsequent repositioning of lips and all other harmful procedures used to harm or mutilate the female genitals are included in type 4. Type 4 includes practices like cauterisation, scrapping, incising, piercing and pricking.

Although criminalised in many developed countries, the WHO surveys have noted that it is still practised in northeastern, eastern and western regions of Africa and in some countries in Asia and the Middle East. It is thought to be a global concern as more than 200 million women in the world have been subjected to it, and 3 million girls are at risk annually. It is performed both by traditional healers and by medical professionals. It is practised due to several reasons. The most important causes are social norms, religious factors, the preparation of females for marriage and pregnancy and the promotion of marital fidelity. Regardless of the objectives or methods used, the FGM practices don't have any health benefits and cause severe issues like constant pain, difficulties during sexual activities, increased frequency of infections resulting in infertility, development of abscesses, cysts and bleeding, problems with urination, depression and other psychological issues and problematic childbirth. 

The long-term complications of genital mutilation are harmful to women's health. The practices involved in general mutilation cause various complications like infections, bleeding, open sores, and permanent damage to the genitals, and the cost of treatment and management of complications is estimated to be 1.4 billion dollars by WHO, and the cost is expected to increase if necessary steps are not taken. It is a criminal offence in most countries, and a United Nations resolution 2012 banned FGM and urged the member states to take necessary steps to protect women. 

What is Female Genital Mutilation?

The term female genital mutilation (FGM) is used for the procedures and practices that are used to cause a total or partial removal of the external genitalia of females and cause an injury or harm to the female genital organs without any medical reason (Obstetrics and Gynaecology, 2018). The practices are performed for various reasons and date back thousands of years, well before the start of major religions. It is sometimes referred to as female circumcision, but it is done for different reasons than male circumcision and has different implications. Besides the traditional healers, it is performed by healthcare professionals, as 77% of cases in Egypt are performed by medical professionals (UNFPA, 2022). It is performed for various cultural, social and religious reasons and is considered a harmful practice and a human rights violation. 

What is the other term for Female Genital Mutilation?

The terms female genital mutilation (FGM) and female genital cutting (FGC) are used interchangeably by medical professionals. Another general term for it is female circumcision. The practice has many names in the traditional literature, and the naming depends upon the country and region. Other terms used in various countries are khitan, megrez, tahur, halalays, gudnin and sunna (Queen Mary University of London). These names reflect the cultural and religious background of the practice. Infibulation is derived from the Latin word 'fibula', which means the clasp. The early Romans used clasps on the labia of the foreskin of the genitals of enslaved women to avoid sexual activities. In Somalia, the practice is called the 'qodob', which means to sew up. In the Mail language, the term 'bolokoli' is used, which means washing your hands, and in Eastern Nigeria, the terms Iwu aru or Isa aru are used, which means having your bath. 

What is the History of Female Genital Mutilation?

Historically, the practice started in the Ancient Egypt, where many circumcised and infibulated mummies were discovered. Gradually, the practice spread along the coast of the red sea to the Arabian and East African tribes. It gradually became a social norm in Ancient Egypt and became a criterion for social acceptance of women, e.g., the inheritance of property and qualification for marriage (University of Virginia School of Medicine).

Some experts believe that the tribal society used it to control the population. The narrowing down of the vaginal orifice by infibulation causes excruciating pain during sex, and it was used to promote fidelity and control sexual desire. It was used as a population control measure in the Darfur region of Sudden, where the arable land was rapidly undergoing desertification. The practices became common as the slave trade expanded, and the demand for enslaved women with stitched vaginas increased as it lowered the risk of impregnation. 

The spread of Islam in Egypt and North and Eastern Africa in the 7th and 8th centuries resulted in the prohibition of enslaving Muslim women and the practice spread towards other regions of Africa where the slave traders used to infibulate the enslaved women to increase their commercial value. Although male circumcision (or Sunna) is a well-established religious tradition in Islam, cutting female genitals in Islamic traditions is debatable. Immigration and the slave trade brought the practice to the West. Some historians believe that it was performed in some regions of Europe and the USA as late as the 1950s to cure the unnatural sexual behaviours of women like depression, masturbation and homosexuality. In the accounts of English gynaecologist Isaac Baker Brown, the endorsement of such acts is found as late as the 1800s (Troy University).

A.J. Bloch, a surgeon in New Orleans, performed a clitoridectomy on 21 years girl accused of masturbating. According to a paper published in the Obstetrics and Gynaecological Surveys in 1985, the clitoridectomy was used in the USA well into the 1960s to treat lesbianism, erotomania (excessive sexual desire) and hysteria.

Beige the 1970s, there was no legislation related to FGM in the UK. It was practised freely in the nineteenth century to treat conditions like distaste for marriage and husband, violent behaviours, hysteria and other mental illnesses. Ultimately, the Obstetrical Society of London declared it to be unethical and found that there is no evidence of its perceived benefits. It again started to be practised in the 1970s and 1980s, and various social groups like the Minority Rights Group (MRG) raised the issue. Consequently, the debate was held in the House of Lords. Finally, the Prohibition of Female Circumcision Act bill was introduced and passed to become law in 1985. It criminalised the practice of FGM for the first time in the UK. Following the 1985 law, the Female Genital Mutilation Act was passed in 2003, which prohibited carrying out or aiding in genital mutilation, infibulation and excision to any part or whole of the vagina, clitoris, prepuce, major lip and minor lip. It criminalised assisting the women to carry out the mutilation and moving abroad or taking the girl abroad for mutilation. 

Despite the legislation, it was noted by the Health and Social Care Information Center that 5,700 new cases of FGM were reported in England in 2015-16 (The Guardian, 2016). Starting from October 2015, it was made a legal duty of the healthcare professionals, e.g., doctors and nurses etc., to report any cases of FGM to law enforcement agencies, and the healthcare professionals failing to report were liable to face action from professional bodies like General Medical Council. Global awareness of the issue is increasing, and the United Nations General Assembly has declared 6th February the International Day of Zero Tolerance for Female Genital Mutilation. However, as the practice has existed for thousands of years, it can't be eliminated easily. Consequently, the UN and other organisations are eventually striving to eradicate the practice by 2030.

How does Female Genital Mutilation work?

Female genital mutilation is of various types, and different procedures are used for each type. The WHO classifies FGM practices into four types, and many subclasses developed later. The procedure, severity (degree of tissue damage) and health risks differ for each type. The procedures for different types are;

Type I: In type 1, the traditional healer or the healthcare professional partially or completely removes the clitoris glans, which is the outer part of the clitoris and is the most sensitive part of the female reproductive system. It may or may not involve removing the clitoral hood or prepuce, which is a fold of the skin surrounding the clitoris glans. So, there are two major variants of type 1; type 1a, which involves the removal of the clitoral hood/ prepuce only, and type 1b involves removing the clitoris glans along with the clitoral hood/ prepuce. The clitoris has a role in sexual arousal, pleasure and orgasm and its partial or complete removal suppresses these sexual processes.

Type II: It involves the complete or partial removal of labia minora and clitoris glans with or without removal of labia majora (the outer skin folds of the vulva). Labia minora are the inner lips of vulva. Depending upon the exact procedure used, there are different subtypes of type II, e.g., type IIa which involve the removal of labia minora only; type IIb, which involves the complete or partial removal of clitoris glans and the labia minora (the clitoris hood/prepuce may be involved), and type IIc that involve complete or partial removal of labia majora, labia minora and clitoris glans (the clitoris hood/ prepuce may be involved). 

The removal of labia is believed to improve genital hygiene and cleanliness, and the complete or partial removal of the clitoris influences sexual arousal and orgasm.

Type III (infibulation): It involves the creation of a covering seal that results in the narrowing of the vaginal opening. The seal is developed by cutting and repositioning labia majora or labia minora. Removing the clitoral hood/ prepuce and glans may or may not be involved as in type I FGM. Depending upon the procedure used, there are two subdivisions of type III, type IIIa, which involves the removal and subsequent repositioning of labia minora and type IIIb, which involves the removal and subsequent repositioning of labia majora. 

Type IV: Type IV is an umbrella term used for different procedures and practices that involve harming the female genitals without any medical reason and include cauterisation, scrapping, incising, piercing and pricking. It includes procures like introducing different substances into the vagina to cause its tightening, burning and scarring of the genitals and symbolic circumcision or nicking of the clitoris. The labia stretching or labia pulling, which involves lengthening the labia minora by using some physical equipment or through manual pulling, is included in type IV too. 

In 1995, the WHO included angurya cutting and gishiri cutting in the list of FGM, which are practised in Niger and Nigeria. However, both were removed from the list as sufficient data was unavailable. The gishiri cutting involves cutting down the front or back wall of the vagina using a penknife or blade and is performed in response to the conditions like obstructed labour and infertility. The angurya cutting involves the scrapping of tissues surrounding the vaginal orifice and is commonly performed within the first seven days after birth. 

The procedures are mostly performed by traditional healers or the circumciser at home with or without anaesthesia. Commonly, an older woman performs the procedures; however, in some communities, the barbers are working. Non-sterile cutting devices like scissors, razors, knives, fingernails, sharpened rocks or glass are used. Sometimes, the healers use one device on many girls without sterilisation. In some countries, healthcare professionals are performing the procedures. For example, 77% of genital mutilations in Egypt and 50 in Indonesia were performed by healthcare professionals (UNICEF).

What is the purpose of Female Genital Mutilation?

Female genital mutilation is carried out for different social, cultural and religious reasons, and these purposes are based upon the mistaken belief that it benefits the women or girls in some way or another. The reasons vary from time to time and region to region, and sociocultural factors have a paramount role. It reflects the existence of deep-rooted inequalities among different genders and the social stigmas associated with male dominance and female reproductive organs. Some purposes of FGM are;

Compliance with social and cultural norms: Many practitioners engaged in FGM have noted that the practice is dictated by culture and traditions, as men in such cultures often refuse to marry intact females. Another stated purpose of FGM is to have control over the sexuality of females, and intact women (without FGM) are thought to be dishonourable and prostitutes. In some societies, e.g., in Niger, where the practice is an accepted social norm, indirect social pressure is exerted on all the people to do what the majority is doing. The fear of facing a reaction from the community and increased social acceptance become major motivations for the practice. 

Preparation of females for puberty: Some traditional societies in Africa and the Middle East believe that prepuce is a sign of femaleness and the clitoris is a sign of maleness, and both structures must be removed before a person is accepted as a mature adult. Some people justify the FGM as useful to enhance the cleanliness and beauty of the females as the female reproductive structures are believed to be dirty and ugly. Some societies perform it to assert male dominance over females.

Religious obligation: Although no established religion supports the practice or requires that women undergo FGM, the patriarchy associated with some religions creates a cultural milieu and allows the practice to continue. Different religious leaders take different positions, and some religious leaders even take part in abandoning the practice. The practice dates back to before the rise of Christianity, Islam and many other established religions, and it tends to move forward as Islam spreads deep into Africa, suggesting that religion has a less role. However, some local religious traditions in the inner African tribes support FGM. 

A necessary part of female upbringing: Sometimes, FGM is considered essential in preparation for adulthood, marriage and pregnancy. It is done to control sexuality to promote marital fidelity and premarital Virginity. It is mostly performed on girls whose mothers, grandmothers and other females in the extended family have undergone it, or the father belongs to a community in which it is a social norm. 

Reasons for medicalised FGM: The reasons provided for a medicalised FGM are variable, and different healthcare professionals provide different reasons to carry out the FGM, e.g., a belief that a medicalised FGM carries lower health risks than a non-medicalised FGM and the belief that medicalising the practice is a useful step towards the eventual abandonment of the FGM. Sometimes, the healthcare professionals engaged in FGM are part of the same FGM practising communities, believe in the same social values and are subject to the same social norms as the other people in the society. In the end, financial incentives in the form of service charges and doctors' fees attract some healthcare professionals. 

Despite all the reasons provided, none are acceptable to the medical community, and no reason justifies FGM. It is now widely accepted that it is a harmful practice, has no benefits for females' reproductive or overall health, and is a gross violation of reproductive and human rights.

What are the causes of Female Genital Mutilation in women?

Various causes and motivations for the practice are provided in the traditional literature. They are mostly based on false beliefs. Some of them are;

1. Social pressure and family traditions: Social norms and pressure are the greatest factors. Some experts have noted that even the people who don't want their daughters to be infibulated eventually find that the procedure has occurred as the girl visited the relatives with her grandmother. Given the importance of older women in upholding family traditions, the Grandmother's Project (GMP) was launched with international funding in Senegal in 2010, aiming to eradicate FGM by educating older women.
2. Promotion of feministic values: The practice is tied to ideas like promoting female chastity, preparing females for marriage and is linked to feminine honour. In traditional societies, females support and transmit the practice to the next generation. 
3. Marking the ethnic and gender differences: Some FGM practitioners have noted that the practice marks gender differences and ethnic boundaries. The proponents hold that male circumcision defeminises men while female circumcision helps emasculate women. 
4. Increasing sexual acceptability: In some societies that support infibulation and other FGM practices, there is a preference for odourless, smooth and dry female genitalia, and for both men and women, the natural vulva is very repulsive. FGM practices are used to achieve that goal. 
5. Better sexual pleasure: The practice enhances the perceived sense of sexual pleasure felt by men, and men in such societies report more pleasure penetrating the infibulated genitals. The local men in these societies have a preference for dry sex. Consequently, women who have not undergone FGM used desperate measures to reduce vaginal lubrication, like introducing tree bark, toothpaste, leaves, Vicks menthol rub, etc., into the vagina.
6. Better sexual hygiene: The infibulation of the vulva results in a smooth vulva that is perceived to be more hygienic by the local people, and FGM practices are performed with the belief that they promote female genital hygiene. 
7. Better social acceptance: Social acceptance is a very strong motive, as researcher Ellen Gruenbaum reported that the girls who have undergone FGM call the uncut girls unclean and unhygienic. 
8. Fulfilling the religious obligations: Some surveys have noted that meeting religious requirements is among the major motives in some regions like Egypt, Guinea, Mauritania and Mali. Although most religions don't have any such obligations, the traditional healers and the people engaged in the FGM practices reinforce the concept by mixing traditions with religious obligations. For example, it is argued that although the practice dates back to pre-Islamic times, it becomes associated with Islam as Islam emphasises female seclusion and chastity (Ahmad and colleagues, Reproductive Health, 2018).
9. Miscellaneous causes: Sometimes, unintentional causes like a lack of information become a very strong cause. The women often have very poor and restricted access to information. Moreover, the circumcisers engaged in the business downplay its association with reproductive health. For example, illness and disease in tribal societies are often attributed to evil spirits, and many people refuse to associate FGM practices with illnesses.

How does Female Genital Mutilation Affect Women's Health?

Despite the legends associated with FGM practices, there are no proven health benefits, and it harms women's health in various ways. The practice involves injuring and removing the normal and healthy reproductive tissues and negatively influences the normal functions of the reproductive organs. There are many immediate health impacts and several long-term effects on the sexual, mental and physical well-being of females.

Regardless of the person performing (traditional healers or healthcare professionals), it is harmful and unacceptable from the public health and human rights perspective. Some healthcare professionals are engaged in the practice. However, the WHO and other health organisations strongly disapprove of it and urge healthcare professionals to avoid it even if the female of her family requests and report the cases to the local law enforcement agencies. The effects on women's health are;

Short-term consequences of FGM

The short-term consequences are related to the procedure itself and are;

Pain: During the process, the sensitive nerve endings and genital tissues are cut, resulting in severe pain during or after the procedure and during the healing phase.

Heavy bleeding occurs when the local blood vessels, like the clitoral artery, are cut. 

Septic shock: The heavy bleeding and wounds often cause acute local infections, leading to septic shock and death in severe cases. 

Infections: The traditional healers perform the procedures without any surgical protocols, using contaminated and the same instruments on many females without sterilisation. It results in severe infections during the active and healing phases. 

Swelling of genital tissues: The infections resulting from the open wounds cause inflammation and swelling. 

Improper wound healing: The infections result in improper wound healing, pain and scarring that disrupts the normal functions of reproductive organs. 

Urinary problems: painful urination and urine retention are common, resulting in pain, swelling and injury to the urethra and bladder. 

High risk of HIV infection: The association between HIV and FGM practices is unconfirmed. However, using contaminated instruments to cut the genitals increases the risk of disease transmission from infected to normal girls. 

Death: Issues like severe bleeding, septic shock and infections like tetanus are potentially lethal. The risk of death is low, and a review noted that 1 out of 500 procedures result in death (Eliot Klein and Colleagues, 2018). 

Mental health issues: Excessive physical force, blunt instruments, and the associated shock and pain are traumatic. The girls feel betrayed by their family members, particularly if they approve and organise the event.

Long-term effects of FGM

The long-term effects influence the long run, and the women continue to experience symptoms for life. These include;

Chronic pain: The tissue damage and the resultant scarring often trap unprotected nerve endings that lead to chronic pain. 

Infections: The risk of different infections is increased. Chronic reproductive tract infections cause genital ulcers, abscesses, cysts, vaginal itch, discharge, pain and chronic pain in the pelvic region and back. If left untreated, the reproductive system infections extend to the urinary system, resulting in septicemia, kidney failure and death. 

Painful urination: The recurrent urinary tract infections and obstructions of urinary system organs, particularly the urethra, cause painful urination. 

Increased frequency of vaginal issues: The women undergoing FGM report a higher frequency of vaginal issues like bacterial vaginosis, abnormal discharges and itching. 

Problems of the menstrual cycle: The obstruction and narrowing of the vaginal opening cause pain during menstruation, difficulty passing out blood, irregular menses etc. The effects are particularly pronounced in women with type III genital mutilations. 

Excessive scaring (Keloids): The wounds caused by the cutting of tissues and the resulting wound healing often leave permanent scars. 

HIV infection: The trauma and injury of the vaginal epithelial allow the direct entry of viruses into the body and facilitate viral infections like HIV. The contaminated utensils used during the process cause infections from the infected to the non-infected people. The results of scientific studies are inconsistent and inconclusive, as noted by a review published in the African Journal of AIDS Research in 2019.

Sexual health issues: The damage to the anatomical structures of the female reproductive system influences the sexual health and overall sexual well-being of the female. The damage to or complete removal of highly sensitive reproductive structures like the clitoris negatively influences reproductive sensitivity and causes problems like poor sexual pleasure, low sexual desire, highly painful intercourse, poor lubrication, difficult penetration and poor frequency or total absence of orgasm. The traumatic memories associated with the procedure, pain and scar formation add to the miseries. 

Complications during childbirth: The women experience issues during childbirth and often need a caesarian section and experience issues like prolonged labour, laceration and tears during childbirth, difficult labour, episiotomy, postpartum haemorrhages, instrumental delivery and other issues that require an increased hospital stay. 

Perinatal risks: In severe cases, the complications during childbirth result in a high frequency of issues like intrapartum stillbirth, infant resuscitation at the time of delivery, and neonatal death.

Obstetric fistula: The direct association between obstetric fistula and FGM practices has not been established yet. However, obstructed and prolonged labour has a relationship with the fistula, and it is supposed that FGM practices increase the risk of obstetric fistula, a hole that connects the birth canal with the rectum or bladder. 

Mental health issues: Various surveys and studies have noted that women and girls having undergone FGM practices are likely to experience issues like aches, pain, depression, anxiety disorders and post-traumatic stress disorder (PTSD). The issues are found even in cultures where the problem is a social norm. 

Irrespective of social norms and cultural and religious significance, female genital mutilation violates human and women's reproductive rights. It carries various long-term and short-term effects and must be discouraged at all levels.

What effect does Female Genital Mutilation have on women's sexual health?

The FGM practices leave short-term and long-term effects on the sexual welfare of women. The mutilations influence all parameters of sexual health, i.e., sexual desire, sexual arousal, lubrication, sexual satisfaction and orgasm. A group of researchers at the University Of Kinshasa (UNIKIN) Democratic Republic Of Congo (DRC) in 2021 noted that women having undergone genital mutilation have lower sexual desire than those without genital mutilation. The results vary with the type of mutilation. For example, Ismail and his colleagues (2017) noted that the women with type III FGM have more marked decrease in sexual desire than those with type I and II.

Poor sexual desire is attributed to various factors like poor lubrication, damage to the sensitive nerves in the genital organs and fear of sex in females due to extreme pain. The FGM practices cause the genital passages to narrow and cause more pain, reducing women's sexual desire. The pain with type III is more than with type I & 2. The same researchers found that the FGM practices suppressed sexual arousal. Normal women (without FGM) are more easily aroused than women with all types of FGM, i.e., type I and type II & e FGM and again, type III causes more suppression of sexual arousal than the other types. The FGM practices reduce lubrication and low intensity of orgasm resulting in poor sexual satisfaction, and again, the effects of type III were more pronounced than those of type I & II. 

Besides sexual dysfunction, FGM practices are associated with various complications during pregnancy and childbirth, e.g., the delivery of an underweight baby, increased risk of newborn death, stillbirth, and increased risk of obstructed labour, which often results in obstetric fistula and increased duration of hospital stays. There is an increased risk of tearing and postpartum haemorrhages in females, and the caesarian section is necessary to facilitate the birth. All types of FGM practices have a negative influence on reproductive health, but type III causes more menstrual and urinary problems, painful sexual intercourse, increased risk of infertility, and requires more surgeries in later life. Due to the vast number of practices involved, the data about type IV is less available. 

Does Female Genital Mutilation have a health benefit for Women?

FGM is not associated with any health benefits and harms women's overall health. There is wide recognition of the negative effects of FGM practices, and no research or survey in the societies that practice FGM has found any medically proven benefits. Due to its negative effects on women's physical and psychological health, FGM is widely condemned, and the global community is trying to eliminate it. It is a human rights violation and the violation of female reproductive rights, and international organizations like WHO are struggling to provide education and support to the masses and provide technical guidance to the professionals with the ultimate aim of eradicating the practice by 2030.

What are the health risks women can get from Female Genital Mutilation?

FGM is associated with many health risks. Some are experienced immediately, while others are experienced in the long run. Some complications result in death, as 1 out of 500 female circumcisions result in death (Eliot Klein, Department of Paediatrics, State University of New York Downstate Medical Center). These include;

1. Immediate risks: Genital mutilation is performed mostly by unskilled practitioners using non-sterilized equipment without anaesthesia and post-operative care. Such people have poor knowledge of the anatomy of the female reproductive system. Bleeding sometimes occurs during or after the procedure. The other issues are infections, swelling, fever, swelling of the genital tissues and shock. Poor wound healing causes scar formation leading to chronic pain and issues with urination. Type III genital mutilation is associated with more severe immediate risks than type I & II. 
2. Genitourinary problems: The women experience various genitourinary issues with a variable frequency. The most common are infections, urological complications, vaginal itching and discharge and damage to the genital tissues. Some other rare issues like abscesses and keloids do occur. Several studies have noted menstrual problems like difficulty passing the menstrual blood, irregular and difficult menses, dysmenorrhea and increased risk of genitourinary infections. 
3. Pain during sexual intercourse: Dyspareunia is a condition in which extreme pain is experienced during sexual intercourse. The narrowing of the genital passages during FGM makes the sexual procedure unpleasant and painful. A study from different regions of Sudan noted that 76.9% of females reported extreme pain during sexual intercourse, particularly those having undergone type III FGM (Khalid Yassin and colleagues, 2018). 
4. High risk of HIV and other sexually transmitted infections: Different cross-sectional studies, meta-analyses and case-control studies have examined the disease transmission. These studies failed to establish any significant relationship with HIV; however, using contaminated instruments during the process carries the risk of disease transmission (UNAIDS, 2008). 
5. Infertility: Some reports of infertility are due to the complications arising from the FGM process. The damage to the vaginal tissues changes the internal environment of the vagina and makes it unfavourable for the sperm. However, the clinical and case-controlled studies have failed to prove any such linkage and little evidence supports the claim that females with FGM are less fertile than females without FGM. There are, however, some reports which do not reach the level of clinical relevance. 
6. Obstetric complications: Obstetric issues like difficult labour, haemorrhages during delivery, instrumental delivery, episiotomy, caesarean section, prolonged labour and lacerations and tears during the process are reported.

What are the different Types of Female Genital Mutilation?

Although the procedure involved is the same, FGM practices are classified into four types for understanding. These are;

1. Type 1 or clitoridectomy involves the procedures and practices used to cause the total or partial removal of the clitoris. 
2. Type 2 or excision: It involves the total or partial removal of the clitoris along with the inner labia (labia minora-the inner lips that surround the vagina). The larger outer lips may or may not be removed.
3. Type 3 or infibulation: It involves narrowing down the vaginal opening by creating a seal by a specific cutting and subsequent repositioning of the lips. It is the most dangerous and invasive type of FGM.
4. Type 4 FGM: All other miscellaneous practices used for genital mutilations fall under type 4, e.g., burning, scraping, piercing and pricking of the genital area.

Type I 

Type I FGM involves the total or partial removal of the clitoris and/or the clitoral hood/ prepuce. The clitoris is the most sensitive part of the female reproductive system, and the prepuce is the skin fold covering the clitoris. Various subtypes do exist, which differ based on the extent and severity of the tissues damaged during the process. It is practised in some traditional societies in Southeast Asia, the Middle East and some parts of Africa. It is performed on young girls during infancy or adolescence and has various names like 'sunna' or female circumcision in some countries. 

The procedure is carried out by traditional healers, midwives, or even untrained people like barbers. These people use unclean and rudimentary tools without proper medical assistance and anaesthesia, resulting in severe pain and stress. The clitoris or the clitoral hood is removed without any medical reason using a sharp razor or knife. There are no medically proven benefits. However, the people engaged in the practice believe it's a religious and cultural obligation, and some people perform it for marriageability and social acceptance. 

There are many negative effects on health. Immediate physical harm and injury result in severe pain, and the traumatic nature of the process carries the risk of transmission of infections, septic shock and death in severe cases. In the long run, it causes complications like chronic pain, sexual and urination issues, and difficulties during sexual intercourse and childbirth. Psychological issues like anxiety, emotional trauma and depression do occur. It violates human and reproductive rights as it infringes the self-autonomy and physical integrity of the females without any known medical or other benefits and is illegal in most countries, including the UK. 

Type II

Type II or excision involves the complete or partial removal of the clitoris and the inner vulval lips (labia minora). It may or may not involve the removal of the bigger outer lips (labia majora). It is more damaging to the reproductive tissues, poses more serious risks than type I, and carries a higher risk of health complications. It is practised in traditional Southeast Asia, the Middle East and some regions of Africa and is mostly performed in adolescence or early puberty by midwives, traditional healers or untrained people like barbers in some regions. 

The people engaged in the practice use crude and unclean instruments like razors, knives, sharpened rocks, etc. The instruments are not sterilized, and no medical procedures, like anaesthesia etc., are followed, resulting in potential health risks like distress and severe pain. There are no proven benefits, and the practice is harmful in all aspects. The people engaged in it provide reasons like religious and cultural norms and promote female marriageability and social acceptability. 

Like in type I, the traumatic and painful nature of the process causes immense physical pain and emotional trauma to the young girls. Immediate complications like blood loss, shock and acute infections carry the risk of death. Long-term consequences include psychological trauma, urinary problems, infections, scar formation, and complicated childbirth. The health risks of type II are higher than those of type I due to the higher tissue damage. There is no medical justification for the process. In rare cases, some healthcare professionals, like in Egypt, do perform it. It is an illegal practice in most countries, including the UK.

Type III

Type III or infibulation is the most invasive and severe type of FGM in which the external genitalia is totally or partially removed, and the labia are repositioned and stitched together. It leaves just a small hole to pass menstrual blood and urine. It is very risky and is universally unacceptable except in some traditional societies. It is practised in some parts of Asia, Africa and the Middle East. Traditional healers perform the procedure, and healthcare professionals sometimes are involved in the practice, like in Indonesia and Egypt (Elise Johansen, Norwegian Centre for Violence and Traumatic Stress Studies, 2018). 

It involves the removal of labia minora (inner smaller lips), clitoris and the clitoral hood. Sometimes, the labia majora is stitched, too and only a small hole is left. There are no pros, and no beneficial effects have been identified, and the practice is universally condemned due to its harmful effects on women's physical and psychological health. However, the communities that practice it believe it to promote cultural norms and preserve female virginity. 

There are many disadvantages and harmful effects. The procedure often results in bleeding, infections and shock leading to death. The procedure's traumatic nature and the fact that it is performed without any anaesthetics or numbing agents result in severe pain, which often becomes chronic. The infections sometimes spread to the urinary system. The narrowed genital passage results in severe pain during sexual intercourse, and there is a higher risk of childbirth complications—psychological trauma results in poor mental health, self-esteem and body image anxiety. The invasive nature of the process violates basic human rights like freedom from pain and violence, body integrity and the right to have optimum health and well-being. It is the target of many international efforts to eliminate the FGM. 

Type IV

The type IV category involves many other practices that are used to harm or cause injury to the female reproductive organs without any medical cause. All other procedures that don't fit into the other types are in the type IV category. The procedures like cauterization, scrapping, piercing, incising and pricking etc., are less invasive than the type III FGM but still cause sufficient risk to the physical and mental well-being of the females. Different practices are carried out around the world due to a variety of social and cultural reasons. 

The procedures involved are variable and are intended to cause genital alterations through minor incisions or major cuts. Both traditional healers and healthcare professionals are engaged in the practice. There are no known health benefits, and the practices are performed for cultural reasons. But, the practices are difficult to justify in light of many risks and complications. Traditional societies use these practices due to the perceived belief in traditional values and practices. 

The health risks and complications are many. The risks are less than the type III, but still, it causes complications like infections and death. The procedures are conducted without anaesthesia and cause severe pain, scar formation and psychological trauma. The practices violate many basic rights of women and girls, including the right to freedom from violence, the right to maintain body integrity and the right to reproductive well-being. The perceived cultural benefits do not outweigh these risks, and the processes are universally condemned and are the target of universal efforts, and many international agencies are involved in eliminating such practices.

What to know more about Female Genital Mutilation (FGM)?

The worldwide efforts to eliminate FGM need worldwide recognition of the problem and public awareness. Despite various public awareness campaigns, some facts still need to be understood by the general public and addressed. Here are less-known facts about FGM. 

It is practised in 29 countries worldwide: Most readers may hear about FGM for the first time. However, FGM practices are way more common. It is practised in 29 African countries, like Egypt, Sudan, Ethiopia, Mali, Chad, Niger, Nigeria, Eritrea, etc. Some countries in the Middle East, like Iraq and Yemen, and in southeast Asia, like Indonesia, have a high prevalence. The highest prevalence is in Somalia, where 98% population has undergone it. The prevalence is 91% in Egypt, and due to its large population, it is home to 20% of victims of brutal practice worldwide. The other countries with high prevalence are Sudan (88%), Mali (89%), Sierra Leone (88%), Guinea (96%), Djibouti (93%) and Eritrea (89%) (World Economic Forum, 2015).

Large variations exist within a country: The prevalence is not uniformly distributed within a country, and some tribes or societies in some parts of the country are more engaged in the practice. For example, in Senegal, the prevalence is 1% or less in some parts of the county and reached 92% in the other parts, giving an average figure of 26%. These differences are attributed to the variable distribution of ethnic groups in various country areas and their different social, religious and cultural norms. 

West, if not free of the practice: While it is highly prevalent in Africa, it is not the sole region, and FGM is practised worldwide. In Europe, more than half a million (680,000) girls and women are affected; in the USA alone, the number exceeds half a million. The figures are high, and despite being illegal and criminalized, the persecutions are very rare, and FGM is still practised in some remote regions (World Economic Forum, 2015).  

There are no proven health benefits: Unlike other cultural practices like acupuncture techniques, FGM has no proven benefits. Male circumcision has some benefits, e.g., good hygiene, less risk of urinary tract infections and sexually transmitted infections and a lower risk of penile cancer. However, female genital mutilation only has risks and complications. The victims suffer several health consequences, like bladder issues and urinary tract infections. Long-term consequences like birth complications and infertility are very common. 

Most women and girls don't like the practice: The survey results showed that most women in countries with high prevalence don't like it and want to stop it. The younger women (15-45) are more critical of the practice than the elder ones (45 or above), and the older women are mostly responsible for keeping the practice alive. UNICEF has noted that women with more reproductive and financial independence are more critical of the practice and want its end.

Most of the males agree too: The men are not indifferent to the sufferings of women, and the surveys have shown that most of the men, even in the regions with the highest prevalence, think that it is a harmful practice and must stop. The only exceptions are the countries like Mauritania, Mali, Guinea, Egypt and Eritrea, where most men believe the practice must continue.

The role of socioeconomic factors is paramount: FGM rates tend to be lower in financially strong and well-off families due to better access to healthcare facilities and education. The daughters of uneducated women are more like to undergo the practice. The practice is more common in rural areas. For example, the prevalence is four times in the rural regions of Kenya than in the urban regions. Lack of access to basic healthcare facilities causes low-income families to rely on traditional healers and be exposed to such practices (UN Women, 2015). 

The most common age is between 5-14 years: In half of the countries where it is practised, most girls undergo the procedures before age 5. Mauritania is an exception where the practice is done much earlier when the girls are one month old. In Bissau and Guinea, one-fifth of the girls are cut after 15 years of age. 

The practice is declining, but not at a sufficient rate: In most countries where the practice is done, the rate of forceful or involuntary mutilations is falling. The rate is falling rapidly in some countries like Tanzania and Kenya, where the surveys have noted that the risk of genital mutilation in daughters is three times less than that in mothers. The rate of decline is more stable in some countries, and some countries like Yemen have experienced an increase in the rate. These figures highlight the need for more measures (NPR, 2013). 

The world is committed to ending the practice: The national and international organizations are working keenly to end the practice, and the UN observes the 6th of February as the International Day of Zero Tolerance for Female Genital Mutilation. It aims to raise mass awareness through massive campaigns and to encourage the member states to take concrete steps to end the practice. The international community has shown its commitment to ending the practice by 2030. 

Despite the harmful effects of Female Genital Mutilation (FGM), why is it still practised?

Despite decades of continuous efforts to eradicate it, FGM is showing resilience and becoming challenging. The experts note various reasons. These factors exist at the individual, organisation, and community levels and are related to the social roles and norms related to gender. 

Factors at the Individual level: At the individual level, the perception that it improves sexual hygiene and has health benefits is responsible. Various wrong beliefs exist in some societies, e.g., it improves newborn survival, easing the delivery process and improving fertility. The practice is more common in females living in rural areas and those having poor financial status. Moreover, the researchers have identified education as an important factor that changes the attitudes about FGM, and the findings of Tamire and Molla (2013) noted that the daughters of mothers with low educational levels are two times more likely to have FGM than those of educated parents. The father's education does not influence the decision-making related to FGM. 

Factors at the Organisational level: In traditional societies, the role of religious leaders, community leaders, circumcisers and medical professionals has an important role in upholding the practice. The medicalisation of the procedure occurs in some regions, even if the practice is illegal. The causes of medicalised FGM, e.g., financial incentives, the belief of healthcare professionals on the benefits of FGM, the benefits of carrying the practice in medical settings etc., curtail the elimination efforts. Religious myths are an important cause as individuals need to fulfil their religious obligations. The religious traditions and the attitudes of religious societies are different throughout the world. However, the practising societies associate the practice with religions like Christianity, Islam and Judaism. Islam doesn't have any such binding obligations. However, the researchers have noted that mixing religion with local culture and the role of people engaged in the practice is responsible for making it a religious obligation. 

Factors at the societal level: At the societal level, families face extreme societal pressure to perform FGM. It's linked to the ideas like female honour and family honour, and the reluctant mothers or daughters are shamed and forced to comply. The uncut girls face stigmatisation and Discrimination from the wider community. They are secluded from social activities and decision-making, and the circumcised women dominate by excluding the uncut women. These factors cause the girls to demand circumcision themselves and are responsible for continuing the practice. 

Influence of the cultural ideologies and ethnic boundaries: The deep-rooted cultural and social ideologies are responsible at the societal levels. Such ideologies influence how parents raise children in such societies, and the societies exert pressure to preserve the ideologies. Consequently, performing the practices like FGM is a way for the girls to show devotion and respect for their family roots and culture. Many girls feel they have no right to refuse the practice, and the WHO has found that society views the circumcised girl as properly raised and dignified. Moreover, it marks ethnic boundaries, which are important for the members of smaller communities like tribal societies. 

Preservation of gender roles and norms: Finally, gender norms and roles in society have a strong influence. It is performed for aesthetic reasons like enhancing the beauty of the female genitals, and the female vagina and other genitals are considered unclean and ugly unless circumcised. The researchers have noted that the sexual morals existing in society have a role, and the females having undergone FGM are perceived to be less sexually active and are easily manageable by their parents or husband. It is thus used to promote sexual morals like fidelity and prevent premarital sex. A girl losing her virginity before marriage is believed to bring shame to the family, as society acts to prevent it by all possible means.

Moreover, the male preferences for circumcised females are due to perceived increased pleasure and more surety about virginity. The women in such societies are mostly sure that the men prefer the circumcised women, although the men seem to have lower concerns, and it causes the girls to demand circumcision. 

How does Female Genital Mutilation (FGM) violate human rights? 

FGM is an invasive and harmful practice and causes injury to the female genital organs. It is performed without the consent of the girls in the majority of the cases. It violates many basic human rights that are guaranteed by international treaties, e.g., 

Right of physical integrity: It implies that every person has the right to have complete physical integrity and must be protected from degrading and inhumane treatment, cruelty and torture. FGM infringes on the physical integrity of the female body, inflicts severe pain, and risks many short-term and long-term complications. 

Right to be free from discrimination: The experts trace the roots of FGM to the inherent gender inequality in some cultures. It becomes a source of gender stereotypes and results in discrimination. Women without FGM face discrimination and criticism from the wider society without fault. The discrimination reduced the ability of women to make decisions about their family and reproductive life. 

Right to health: Serious complications arising during or after the mutilation, e.g., childbirth complications, reproductive issues and urinary tract infections, harm the physical and psychological health of the women. It compromises the basic right of every woman to enjoy optimum physical and psychological health. 

Right to be safe from violence: Almost all types of FGM practices are violent and violate the basic human right of being free from violence. The violence is perpetrated without any balancing benefit. 

Right to information and education: The complications arising from FGM practices hinder girls' education. In most cases, the girls are not informed about the procedure. The so-called culture of silence harms basic human rights, as the girls are unaware of what is happening to their bodies. 

Right to dignity: It implies that it is the right of every person to be respected and valued for their own sake and must be treated ethically. FGM degrades the females and causes psychological distress, humiliation and shame and compromises the right to respect and dignity. 

International treaties related to the human right like The United Nations Convention on The Rights of the Child (UNCRC), the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) and, above all, the Universal Declaration of Human Rights (UDHR) all unanimously condemn FGM and stress the need to eliminate it by all possible means like community awareness, mass education and legal measures.

Why Female Genital Mutilation (FGM) is considered illegal?

FGM practices are considered illegal due to various issues related to human rights, promotion of gender inequalities and the potential health risks. Each country has its jurisdiction to deal with the situation. However, some common grounds for its illegal status are;

A violation of human rights: FGM practices violate many basic human rights like the right to be free from violence, the right to have physical integrity, the right to have information about the body and health, the right to education and the right to be free from inhumane treatment and torture. FGM violates basic human rights protected under various international treaties and conventions. 

Potential health risks: FGM practices, particularly type III, are associated with various risks to female health and cause injuries, severe pain, bleeding and infections. Long-term complications like increased risk of infections like HIV, complicated childbirth and various reproductive and urinary problems are very serious. The high risk of health complications without health benefits is why it is illegal in many countries.

Gender inequality: The roots of FGM practices lie in gender inequality as it is done to reinforce male dominance and discriminate the women. It is associated with many gender-related biases and stereotypes that limit females' physical integrity and autonomy. Consequently, the practices do not align with the international efforts to promote gender equality and end gender discrimination. 

Child protection: FGM practices are mostly performed in infancy or at a very young age and harm the child's health, and the child is subjected to many dangerous complications. Every child has a right to grow in a safe environment that promotes their mental and physical well-being. So FGM is banned to safeguard these fundamental rights of the child. 

International commitments: Many international treaties have condemned and illegalised FGM, and the countries sighing these treaties and conventions are obliged to make legislation to end the practice. Local legislations use references to international treaties for that purpose. For example, the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) obligates the member states to make appropriate legislation to end the practice. 

Concerns about public and community health: The community's increasing awareness about the harmful effects of FGM and its lack of benefits creates strong social pressure to ban the practice. Banning practice has several causes and is a criminalised offence in most countries.

How widespread is the practice of Female Genital Mutilation (FGM)?

The terms prevalence and incidence are used to describe the disease occurrence. Prevalence means the proportion of people in a region who have the disease at some point, while incidence means the percentage or proportion of people who develop the disease within a period. FGM is highly prevalent in many countries in Africa, some countries in the Middle East, like Yemen and Iraq and in Southeast Asian countries, like Indonesia and Malaysia. Some indigenous people or migrants in Australia, the USA and Europe are engaged in the practice. 

The UNICEF data collected from multiple surveys published in June 2023 found that over 200 million girls have undergone the practice in at least 31 countries worldwide (FGM, UNICEF, 2023). The report included the countries with a significant prevalence only, and the countries with minor prevalence, like USA and UK, were not included. It doesn't include data from some countries where it is known to be practised, like Qatar, United Arab Emirates, Oman, Syria and Jordan. Data reliability could be better as it is based on self-reporting and verbal surveys, and no large-scale clinical examination studies have been undertaken. 

It is based on the assumption that the women will answer correctly when asked about FGM and ignores that talking about genitals, particularly those of females, is a taboo in traditional societies (which are mostly engaged in the practice). For example, the surveys have found that many people of the opinion do not like to talk about the practice due to the fear that it discloses the secrets of their culture and will attract universal condemnation of the practice they believe they must continue on religious grounds. 

In the countries where it is illegalised, the fear of persecution of self or a family member is responsible for deniability and underreporting of the practice. For example, a survey in Ghana noted that 13% of the same women denied having undergone FGM when asked five years after banning the practice (Alissa Koski and Jody Heymann, BMC Global Health, 2017). Consequently, after including all these variables, the projection data has estimated that the number of females to have undergone is likely at least to be at least 250 million. 

Which regions or countries have the highest prevalence of Female Genital Mutilation (FGM)?

The highest known prevalence of FGM is in 30 predominately African countries. However, UNICEF has noted that it may be practised in at least 50 countries in Africa, Middle East, Latin America, Eastern Europe and Southeast Asia. The African countries with the highest prevalence are in a band stretching from Senegal (on the Atlantic coast) to Ethiopia, which lies on the east coast. From north to south, the FGM belt stretches from Egypt to Tanzania. 

Ganiyu Shakirat from the California Institute of Behavioural Neurology and Psychology published research about female circumcision in Africa in 2020. According to it, the highest known prevalence of FGM in girls under 14 years was in Mali, where 73% of the girls have undergone FGM. The other countries were Gambia (56%), Mauritania (51%), Guinea (56%), Djibouti (43%), Eritrea (33%), Sudan (30%), Guinea- Bissau (29%), Ethiopia (16%), Senegal (14%) and Nigeria (13%). In Egypt, most FGM is performed by medical professionals, and according to World Economic Forum, it is home to 20% of total victims of FGM due to its large population. 

It is important to note that the above research has provided age-restricted data rather than the prevalence for all higher age groups, as given in the above sections. The African countries with the highest prevalence are on the east or west coast. Both were the centres of the slave trade, and the practice is likely a heritage of the slave trade. 

The prevalence within a country is not uniform and changes with the distribution of religious and ethnic groups that practice it. A case example is Senegal, where some regions of the county have 1% while others have more than 90% prevalence. The preference for each type was different. For example, type III FGM is the most commonly used FGM procedure in Djibouti; two-thirds of all women undergo it. Likewise, the data for different religious groups differs, and the prevalence is highest in Islamic communities. For example, 92% of Muslim women in Ethiopia undergo the procedure. It is very high in comparison to other religions like traditional religions (55%), Roman Catholics (58.2%) and Protestants (65.8%).

How can girls and women who have had Female Genital Mutilation (FGM) help their health and general well-being?

The women and girls who are the victims of this brutal practice must take the necessary steps to avoid negative health outcomes. It must be remembered that the best way is to avoid the practice altogether. Some steps that the affected individuals must take are; 

Immediately seem medical care: A regular medical checkup and consultation with the healthcare professionals help to have a continuous watch and timely address any possible complications. The doctors provide guidelines about the management of pain and reproductive health issues. 

Seek emotional and psychological support: The women must seek counselling and help from mental health professionals, friends and family members, professional counsellors and community support groups. Such measures are useful to address the issue like emotional trauma etc. Sharing feelings and experiences with the other victims and experts is a way to cope with the stress. 

Take legal support: Taking legal support and protection and being aware of one's reproductive rights is very important, particularly in countries where the practice is illegal. The legal procedures are useful to ensure justice and keep the problem under check. 

Self-education and awareness: It is important to be aware of the harmful effects of the practice and its legal status in the country. Education is very useful in breaking the cycle for the benefit of future generations. 

Inform the Gynaecologist about FGM status: Patients with FGM often need a caesarean section for delivery. So, the victims must inform the doctor about their FGM status to avoid birth complications. 

Advocate actively for change: The survivors and victims must raise a strong voice and generate enough social pressure to end the practice. Sharing the stories of personal suffering helps drive a positive change in society by motivating parents and influencing policymakers and community leaders. 

Engage in community outreach: Many international organisations and non-profit organisations are working in the areas with high prevalence. The victims must work with them and actively participate in awareness campaigns and activities. 

Develop and maintain healthy relationships: Developing healthy and respectful relationships and having good cooperation and communication with the partner are useful to ease life. Mutual respect, trust and consent are useful and very important for healthy relationships. 

Does Mental Health Illness a factor for women to decide to undergo FGM?

No, mental health illnesses have no role in the decision-making related to FGM. The decision is based on social, cultural and traditional factors and is mostly perfumed without the victim's consent. In most cases, the victim is an undergrad girl or infant who is unable to make any decisions or arrangements. The mental health conditions like depression, anxiety and post-traumatic stress disorder (PTSD) are among the consequences of FGM.