Medical News 2013, 82, 6, 458–462
STANISŁAW ANTCZAK, AGNIESZKA ŻOK
FEMALE GENITAL MUTILATION IN SUB-SAHARAN AFRICA
AS A HEALTH AND CULTURAL PROBLEM
OBRZEZANIE KOBIET W AFRYCE SUBSAHARYJSKIEJ JAKO PROBLEM ZDROWOTNY I KULTUROWY
Laboratory of History of Public Health and Social and Health Policy, Chair of Social Sciences
Poznan University of Medical Sciences, Poland
Head: prof. Michał Musielak
Abstract
Female genital circumcision is defined as all procedures that involve partial or total removal of the external female genitalia, or
other injury to the female genital organs for non-medical reasons. This painful procedure leads to serious health consequences, the
circumcised women are exposed to health complications immediately after the procedure but some sequels of the procedure trouble
them throughout their life. According to approximate calculations of WHO, still 100 to 140 million of girls and women all over the
world have been subjected to circumcision. In the context of our analysis the most relevant seems to be understanding of a culture
as a set of common rules which decisively affect behavior of members in a community or society and „a set of values, beliefs and
attitudes shared by most of community members”. Such norms are inherited from generation to generation and control almost all
aspects of functioning in the human community.
KEY WORDS: FGM, culture, Africa, reproductive health.
Streszczenie
Obrzezanie kobiet, rozumiane jako wszelka ingerencja w żeńskie zewnętrzne narządy płciowe z przyczyn niemedycznych, jest
bardzo bolesnym rytuałem mającym poważne konsekwencje zdrowotne. Mimo to, według danych opublikowanych przez Światową
Organizację Zdrowia, od 100 do 140 milionów dziewcząt i kobiet na świecie poddano temu bolesnemu rytuałowi. W kontekście
dokonanej analizy szczególnie istotna wydaje się kwestia odniesienia obrzezania kobiet do obowiązujących w krajach Afryki
Subsaharyjskiej kultur. Kultura jest tu rozumiana jako zbiór wspólnych zasad, które zdecydowanie wpływają na zachowanie
użytkowników społeczności lub społeczeństwa oraz zestaw wartości, przekonań i postaw podzielanych przez większość członków
wspólnoty. Normy te są dziedziczone z pokolenia na pokolenie i kontrolują niemal wszystkie aspekty funkcjonowania w społeczności
ludzkiej.
SŁOWA KLUCZOWE: obrzezanie kobiet, kultura, Afryka, zdrowie reprodukcyjne.
Female circumcision, practiced nowadays in several
countries, is defined as all procedures that involve partial or total removal of the external female genitalia, or
other injury to the female genital organs for non-medical reasons [1]. According to evaluation made by WHO,
procedures of the type are performed in 28 countries of
western, eastern and north-eastern Africa as well as in
some countries of middle-eastern Asia. The practices
are also transferred by diasporas originating from Africa to Europe, North America and Australia [2]. According to approximate calculations of WHO, between 100
and 140 millions of girls and women all over the world
have been subjected to circumcision [3]. Most frequently, the female genital mutilation is performed on girls at
the age just few days before pubescence period. The circumcision used to be performed in conditions far from
those which used to characterize professional medical
offices, using „traditional tools”, such as a knife, razor,
piece of razor blade, glass or another sharp-pointed
object. The wound resulting from the mutilation used
to be supplied using a plant thorn, fisherman’s string or
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hairs. The tools used for „the procedure” are not subjected to sterilization, which leads to serious health consequences. Female circumcision results in much more
serious health consequences than those induced by circumcision of boys.
Wiesław Jaszczyński, a physician practicing for two
years in Egypt has described the way in which the procedure is conducted. The girls are not prepared for the procedure in any professional manner. The clitoris is brushed
with nettle leaves to induce its reddening and swelling,
the operator elevates it maximally upward using forceps
and cuts it off using a sharp object. Bleeding used to be
not staunched, just the wound is overplayed with rottenness plants or even animal faeces [4].
Experts of WHO, UNICEF and UNFPA distinguish
four types of Female Genital Mutilation:
– Type I: partial or total removal of the clitoris and/or
the prepuce (clitoridectomy). In type I one can distinguish subgroups: type Ia, removal of the clitoral hood
or prepuce only; type Ib, removal of the clitoris with
the prepuce.
Female genital mutilation in Sub-Saharan Africa as a health and cultural problem
– Type II: partial or total removal of the clitoris and
the labia minora, with or without excision of the labia
majora (excision). In type II one can distinguish subgroups: type IIa, removal of the labia minora only;
type IIb, partial or total removal of the clitoris and
labia minora; type IIc, partial or total removal of the
clitoris, labia minora and labia majora.
– Type III: narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or
without excision of the clitoris (infibulation). In type
III, one also can distinguish subgroups: type IIIa,
removal and apposition of the labia minora; type IIIb,
removal and apposition of the labia majora. Reinfibulation is covered under this definition. This is a procedure to recreate an infibulation, for example after
childbirth when defibulation is necessary.
– Type IV: unclassified – all other harmful procedures
to the female genitalia for non- medical purposes, for
example, pricking, piercing, incising, scraping and
cauterization [1].
FGM procedure may include also incisions/scarification of perineum and vaginal walls and introduction of
corrosives and herbs into vagina. All the procedures
are performed without anaesthesia. In some regions the
the FGM-subjected girls are administered with herbs os
anaesthetic properties, but taking into account the so
intense pain, their effect is doubtful.
The so drastic procedure leads to serious health
consequences, the circumcised women are exposed to
health complications immediately after the procedure
but some sequels of the procedure trouble them throughout their life.
The direct health consequences are linked, first of
all, with a nagging pain, resulting from transsection of
nerves in female genitals, intensely supplied with nerves.
Also the healing period, particularly long and painful in
the case of FGM type III, is a very persistent experience.
The pain and bleeding result in a post-traumatic shock.
Moreover, the girls subjected to the third type of FGM are
exposed to the risk of a „reparative” circumcision, resulting from improper healing of the wounds. Persistent pain
accompanies urination and problems with urination frequently trouble the circumcised women throughout their
life. This is so because the suturing of perineum levaes
behind just a small opening, supposed to permit urination and menstrual bleeding. The situation leads also to
frequent infections. The circumcised women frequently
experience serious problems with their gynaecological
health. They may not be able to pass all of their menstrual blood. They may also have infections over and over
again. It can also be hard for a health care professional
to examine a woman’s reproductive organs if she has had
a more severe form of FGC. Normal tools cannot be used
to perform a Pap test or a pelvic exam [5].
Serious health consequences may also result from
the manner in which „the procedure” is performed. The
tools used in its course are not sterilised, which is linked
to an elevated risk of infection transmission, involving
459
HIV, STD or viral hepatitis between persons exposed
one after another to FGM.
Serious health consequences of FGM include also
problems related to sexual life of the women subjected
to such a procedure. The most severe form of FGC leaves
women with scars that cover most of their vagina. This
makes sex very painful. These scars can also develop
into bumps (cysts or abscesses) or thickened scars (keloids) that can be uncomfortable [6].
Also, FGM is not neutral for psychic health of the
victims. This procedure is typically performed on very
young girls. Some may not understand what is being
done to them or why. The psychological effects of this
painful experience are similar to those of post-traumatic
stress disorder [7].
FGM brings about enormous problems related to
reproductive health. Apart from the above mentioned
problems with sexual life complications are encountered
during delivery and they can be risky for life of the newborn: studies confirm an increased risk for an intrauterine foetal death and an increased mortality of respective
newborns. The risk of complications and risks for the
foetus and the newborn depend on the type of the performed procedure. In type I FGM the risk is increased
by 15%, type II FGM increases the risk by 32%, while
in women subjected to type III FGM the risk of complications during pregnancy and delivery is increased by
as much as 55% as compared to women not subjected to
FGM. Moreover, Wiesław Jaszczyński claims that the
procedure of infibulation results in infertility in around
10% women subjected to this procedure [8]. The consequences of FMG for the course of delivery have been
pointed out also by Nura Abdi, who recalls experience of
her own mother linked to her own delivery: „As for every
circumcised woman, also for my mother delivery presented a severe torture. She suffered for five hours even
if a midwife performed episiotomy. And just after I was
born she was sutured again. It had to be so, this was what
experienced all Somali women and my mother without
protest had to subject to this for already the fourth time”
[9]. Similar practices in Nigeria were described by Ilona
Maria Hilliges, graduate of Third World sociology, specializing in topics related to Africa. „Delivery following
circumcision used to provide a bloody torture. Nevertheless, almost all women agree to be sutured again to preserve their attractiveness to their husbands” [10]. Apart
from this the delivery following circumcision brings
about serious risks both for the delivered child and for the
delivering woman since „a child delivered through the
so reduced opening may be choked up while the mother
may bleed out to death” [11]. All the risks for the delivering circumcised woman should be supplemented by the
risk of ruptured tissues during delivery, increased bleeding, diastasis of wounds and an excessive load not only
to pelvic floor but also to the newborn. Finally, circumcision increases risk of infection with sexually transmitted diseases, including HIV infection [12]. Circumcised
women living in diaspora in Europe after getting pregnant full of anxiety are confronted with a double probREVIEW PAPERS
460
Stanisław Antczak, Agnieszka Żok
lem. One of them involves clear fear of delivery and the
other the need to take advantage of assistance of a physician, frequently a man, against their own cultural rules
which forbid contacts of the type [13].
Since circumcision precipitates the so numerous negative health consequences of both somatic and psychic
nature it is worth to consider why so drastic procedures
continue to be widely practiced in some societies.
The most important factors which in a decisive way
shape human behaviour include cultural heritage. Individual cultures frequently in a significant way differ
from each other and the contemporary form of the world
manifests an extreme cultural variability. Clarification of
forms and of significance of cultural effects requires that
the terms should first be well defined. The choice of an
appropriate way in which the term should be understood
poses a difficult goal because the scientific terminology
contains an extreme number of definitions of a culture.
In the context of our analysis the most relevant seems to
be understanding of a culture as a set of common rules
which decisively affect behaviour of members in a community or society and „a set of values, beliefs and attitudes shared by most of community members” [14]. Such
norms are inherited from generation to generation and
control almost all aspects of functioning in the human
community. Thus, the so understood culture constitutes
a specific property of a social, national or tribal group and
represents one of principal factors affecting the process
in which identity of an individual is shaped and, in this
way, which is „programming” of his/her mind. Cultural
norms determine the way in which causes and course of
diseases are perceived, the choice of their treatment but
represent also a significant source of differences in the
way health problems are perceived and in the preferred
strategies of resolving the problems. Conditioning of the
social/cultural nature exert also a decisive effect on the
shape of our views on human body since it affects also
the relationship between culture and health. The question acquires a particular significance in the context of
problems linked to female circumcision in Africa and the
resulting consequences for the altered shape of female
external genital organs [15].
Female circumcision has no religious background:
in Africa it is practiced by Moslems, local Christians,
Fellasha Jews and by animists. It reflects local, deeply enrooted African tradition, the beginnings of which
reach back four hundred years [16]. Among the traditional values providing base for cultural identity of an
African man a specific role is played by values linked to
a traditional African family. They include respect for the
elders, which warrants continuation and transfer of tradition and the honour, aimed to assure observation of the
compliance with orders of the local moral code. Moreover, a significant role among the fundamental values is
played by maternity, assuring coherence of the group in
time and provision of progeny. It symbolizes prosperity and tribe continuation and it warrants an appropriate standard for the family [17]. Pointing to significance
of the ritual, Jomo Kenyatta, later the first president of
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independent Kenya said that „initiation is not reduced
only to sexual life, it also provides a hard lesson of
respect for the elders and of obligations toward the country” [18]. For this reason he was an ardent advocate and
a defendant of circumcision ritual while his book „Facing Mount Kenya” (London 1938) „provides an apoteosis
of initiation as an extremely important institution in an
educational process and a significant element of patriotism of Kikuju people” [19].
Circumcision exerts a significant effect on female status in the community in which she lives and on honour
of her family. It provides also an indispensable condition
for establishing marriage since an uncircumcised woman
has no chances to find a husband in a society which practices it. This was confirmed by Khady, a female author
originating from Soninké people, inhabiting Senegal.
She wrote that „a worthy his family Soninké would never marry an „unclean” girl” [20] since, according to the
author, multi-year tradition requires that parents should
for their daughters „an appropriate preparation for roles of
a wife and a mother, circumcision and selection of a husband. For them neglect of such a duty would harm their
daughters much more than circumcision” [21]. Girls who
would not be subjected to circumcision would be exposed
to social stigmatization and, due to this, to isolation or
even exclusion [21]. Just for these reasons, the girls themselves want to be subjected to the procedure. In a report
prepared by UNICEF its authors draw readers’ attention
to the fact that genesis of the cruel custom is enrooted in
the male fear of female sexuality present in several African cultures and male attempts to control it. Circumcision is thought to reduce sexual drive in women, which
favours her moral behaviour [22]. Attempting to clarify
practice of this „bloody ritual”, Bruno Bettelheim, a representative of the so called psychoanalytic microanthropology, quoted views of F. Bryk, another investigator also
representing psychoanalytic orientation, who thought that
„excision of the external centre of stimulation reduced
sexual freedom of a Nandu girl and in this way the girl
becomes transformed from a generally accessible property to a private one, the exclusive property of her husband.
This meant that, in opinion of the investigator, removal of
the easiest to stimulate externally exciting organ attenuated female sexual drive. According to him this was the
only way to enforce monogamy in the female, „a monogamy which contradicts female nature” [22]. The author,
however, continued quoting the marginally distinct from
the preceding one opinion of Maria Bonaparte. The latter author thought that submitting girls to the crude excision procedure aimed not at promotion of their feminization but rather at their sexual intimidation. According
to the female investigator „some men wish that a female
carries in herself nothing which is male. The elements
which in a female seem to be phallic provides them with
a source of anxiety and therefore they require elimination
of external stimulation organs in females” [23]. Moreover, the investigator thought that „ all the customs seem
to provide satisfaction only in the sphere of imagination
in humans who introduce the customs (…) and no female
Female genital mutilation in Sub-Saharan Africa as a health and cultural problem
mutilation can cause that a man uncertain of his masculinity will feel less endangered by women” [24].
In several societies uncircumcised women are regarded unclean and even treated as harlots, which in practice
excludes them from social life. The arguments for subjecting a female to circumcision used to include her chastity, certainty as to her virgin character up to the day of
marriage and, ironically, hygiene, aesthetics and health.
In this case various prejudices play a significant role [25].
„In certain countries people think that uncircumcised
women cannot deliver a baby or that contact of a newborn with clitoris induces death of the newborn” [12].
Joseph Campbell, an eminent anthropologist and a specialist in matters of religion presented a concept enrooted
in the African tradition, according to which cliterodectomy involving removal of clitoris in a woman is substantiated by the fact that „(…) humans are delivered in an
androgynic, male-female form and circumcision is supposed to release full masculinity from a mother’s womb.
This is how it is symbolically interpreted. In a similar
way removal of clitoris eliminates the male element and
the person becomes fully female. The ritual takes place
during pubescence” [26]. In turn, another anthropologist,
Nigel Barley, accentuated that a clitoris used to be taken
as a rudimental form of the penis, which should not be
present in women since the substitute of male penis casts
doubts as to their feminity. Therefore, „it is required that
culture should correct the imperfect nature” [27]
Also Africans share the conviction that a circumcision-subjected woman will not break somebody’s else’s
marriage. Occasionally, African women trust that a circumcision-induced sexual frigidity represents a price
which has to be paid for reduction of temptations which
draw off men from the family. The earlier quoted Khady,
originating from Senegal, wrote: „Women accuse men
that they initiate the „operation” but in many villages
fathers are not informed about it unless the circumcision
is performed in common, treated as an initiating ritual,
when entire village knows about it. In towns, on the other hand, the procedure is conducted in privacy so that
neighbours should know nothing about it” [20]: contemporary African towns are inhabited mostly by multi-ethnic people which not necessarily practice the same customs and frequently are adherent to frequently very distinct traditions. Finally, it is worth stressing that in view
of protests and condemnation of the practice in the western world many African women begins to treat circumcision as a symbol of African identity. A similar view is
presented by some marginal relativists and cultural pluralists in the western world. In their opinion representatives of the West enjoy no rights to criticize practices
cultivated in other societies, such as ritual mutilation of
female sexual organs [28].
References
1. World Health Organization. Global strategy to stop healthcare providers from performing female genital mutilation.
2010:1.
461
2. World Health Organization. Eliminating Female Genital
Mutilation. 2008:4–28.
3. World Health Organization. Female Genital Mutilation:
integrating the prevention and the management of the
health complications into the curricula of nursing and midwifery, a teacher’s guide. Geneva; 2000.
4. [Internet] Jaszczyński W. Obrzezanie kobiet [accessed:
12.08.2012]. Available at: www.racjonalista.pl/kk.php/
s,3140.
5. [Internet] [accessed: 19.10.2011]. Available at: http://www.
womenshealth.gov/publications/our-publications/fact-sheet
/female-genital-cutting.cfm.
6. [Internet] GHN [accessed: 19.10.2010]. Available at: http://
ghanahealthnest.com/female-genital-mutilation-the-faqs/
7. WHO. An update on WHO’s work on female genital mutilation. Progress report. 2011.
8. World Health Organization. A Systematic Review of the
Health Complications of Female Genital Mutilation including Sequelae in Childbirth. Geneva; 2000: 1–186.
9. Abdi N, Linder LG. Łzy na piasku. Warszawa; 2008: 30.
10. Hilliges IM. Biała czarownica. Warszawa; 2008: 126.
11. Dirie W, Miller C. Kwiat pustyni. Z namiotu nomadów do
Nowego Yorku. Warszawa; 2007: 168.
12. Dirie W. Milborn C. Przełamać tabu. Warszawa; 2005:
168.
13. Dirie W, Miller C, Widy M. Życie codzienne
w muzułmańskim Paryżu. Warszawa; 2005: 89.
14. Tavris C, Wade C. Psychologia. Podejście oraz koncepcje.
Poznań; 1999: 372; Staszczak Z, editor. Słownik etnologiczny. Terminy ogólne. Warszawa-Poznań; 1987: 187–191.
15. Matsumoto D, Juang L. Psychologia międzykulturowa.
Gdańsk; 2007: 251–255. Hofstede G, Hofstede GJ, Minkov M. Kultury I organizacji. Zaprogramowanie umysłu,
Warszawa; 2011: 20–23. Weisner TS. Kultura, dzieciństwo
I postęp na obszarze Afryki Subsaharyjskiej. In: Harrison
LE, Huntington SP, editors. Kultura ma znaczenie. Poznań;
2003: 228–232.
16. Veran S. Krwawa tradycja. Francja wypowiada walkę
obrzezaniu dziewczynek przez niektórych imigrantów
z Afryki. Observateur, 4–10.02.1993. Forum. 1993;11:21.
17. Szupejko M. Afrykańska tożsamość u progu XXI wieku.
Anglojęzyczna literatura Czarnej Afryki i jej twórcy. Warszawa; 2007: 47. On the role of family see also: Vorbrich
R. Plemienna i postplemienna Afryka. Koncepcje I postaci
wspólnoty w dawnej i współczesnej Afryce. Poznań; 2012:
27–35. Dozon J-P. Afrika: Die Familie am Schceideweg,
Geschichte der Familie, Burguiẻre A, Klapisch-Zuber C,
Segalen M, Zonabend F. Band 3, Neuzeit, Frankfurt/Main;
1997: 385–433.
18. Zins H. Historia Afryki Wschodniej. Wrocław; 1986: 161.
19. [Internet] Kenyatta J. Available at: http://en.wikipedia.org/
wiki/Jomo_Kenyatta.
20. Khady. Okaleczone, Warszawa; 2007: 166; Kazimierczyk M. ONZ bije na alarm. Szokujący raport o obrzezaniu. Gazeta Wyborcza. 2005 November 26–27.
21. Hussein MA. Obrzezanie dowodem kobiecości. Rzeczpospolita. 25th November 2005. Significance of initiation ritual;
see also: Słownik etnologiczny. Terminy ogólne. 160–161.
22. Bryk F. Die Beschneidung bei Mann und Weib, Neu Brandenburg; 1931: 279, quoted after Bettelheim B. Rany symboliczne, rytuały inicjacji i zazdrość męska. Warszawa;
1989: 271.
REVIEW PAPERS
462
Stanisław Antczak, Agnieszka Żok
23. Bettelheim B. Rany symboliczne, rytuały inicjacji
i zazdrość męska. Warszawa; 1989: 271–272.
24. Bonaparte M. Notes on Excision, in: Psychoanalysis and
the social Science, New York 1938, vol. II, 81, quoted after:
Bettelheim B, 272–273. See also: Piłaszewicz S. Religie
Afryki. Warszawa; 2000: 145.
25. Staszczyk Z, editor. Słownik etnologiczny. Terminy
ogólne. Warszawa–Poznań; 1987: 297–299.
26. Campbell J. Kwestia bogów. Warszawa; 1994: 66.
27. Barley N. Plaga gąsienic. Powrót do afrykańskiego buszu.
Warszawa; 1998: 49.
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28. Harrison LE. Dlaczego kultury nie sposób przecenić? In:
Harrison LE, Huntington SP, editors. Kultura ma znaczenie. Poznań; 2003: 29.
Correspondence address:
Laboratory of History of Public Health and Social
and Health Policy
Chair of Social Sciences
Poznan University of Medical Sciences
79 Dąbrowskiego Street, 60-529 Poznań, Poland
phone: +48 61 854 68 39
email: [email protected]