Female genital mutilation: Scars that refuse to heal

Female genital mutilation is on Egypt's political agenda again, after the death of two young girls. But can legislation banish this traumatic practice?

Karima Rahim Massoud, a 13-year-old Egyptian girl from a village in the Nile Delta province of Gharbiya, died due to complications with the anaesthesia administered during a procedure popularly referred to as “female circumcision”, but which is more accurately described as female genital mutilation.

Her father, not wishing to alert the authorities to the illegal surgery his late daughter had undergone, tried to pass her death off as being due to “natural causes”. I wonder how the man must have felt during his dismal attempt to save his own skin so soon after costing his daughter hers. The doctor who performed the operation has been referred to the public prosecutor and his clinic has been shut down.

A medical examination revealed the father's claims to be false and the story was all over the Egyptian press on Saturday. The international media soon followed suit.

For those unfamiliar with it, there are several types of female genital mutilation (FGM) categorised according to their severity. Type I, known as a clitoridectomy, involves the removal or splitting of the clitoral hood. Type II, or excision, entails the additional partial or total removal of the inner lips of the vulva. Type III, infibulation or “pharaonic circumcision”, is the most extreme form and involves extensive tissue removal of the external genitalia, leaving a raw open wound. Type II is the most common in Egypt.

Karima's was the second such death in the last few weeks. In June, the death of Budour Ahmed Shaker, 12, caused public outrage and calls to re-impose a ban on this cruel practice.

In June, the Egyptian health ministry responded with a decree banning all doctors or other personnel from carrying out FGM operations at any time or under any circumstances. Following the latest tragedy, the government has promised to fast track new legislation when parliament reconvenes in the coming weeks.

Religious leaders have leant their muscle to the cause and Egypt's first lady, Suzanne Mubarak, has been an outspoken opponent of FGM. The grand sheikh of Cairo's al-Azhar mosque, Mohammad Sayyed Tantawi, Egypt's foremost authority on Islam, and the Coptic patriarch Pope Shenouda III have both declared that FGM has “no foundation in the religious texts” of either Islam or Christianity.

Mahmoud Hamdy Zakzouk, the Egyptian minister of religious endowments (awqaf), called on all imams to condemn the practice as un-Islamic in their Friday sermons. “During your Friday sermons, you must stress that female circumcision is just one of the ‘bad' habits widespread in some countries of the Nile basin, including Egypt, and that it is not at all a sign of Islamic worship”, he told potential imams during a training session at the Nour mosque in Cairo.

Egypt's National Council for Childhood and Motherhood has set up an FGM hotline, a freephone number staffed 24 hours a day, to answer the queries and concerns of parents and to enable concerned citizens to report any illegal operations.

The alarming figures tell a depressing story. In 2000, a USAid-funded study of over 15,000 Egyptian women found that 97% of them had undergone FGM. Accustomed only to seeing that kind of overwhelming majority in Egyptian presidential elections (and even there, this has fallen off), I find the figure hard to swallow, because I'd always been under the impression that the practice was rare among the urban population.

Mohamed Badawi, an epidemiologist at the Johns Hopkins Bloomberg School of public health, collated the findings of several surveys to reach an average of just over 80% – hardly more heartening. That means that at least four out of every five of the thousands of Egyptian women I have met in my life have been scarred by this shocking practice of female genital mutilation at sometime between their sixth and 11th birthdays.

The medical consequences can de deadly. Although the two girls mentioned above died of anaesthesia-related complications, many more die of excessive bleeding, contamination due to the use of unclean instruments by unqualified personnel, or death through shock when no anaesthetic is used in underground operations performed by village midwives. Although most girls survive, the trauma scars them for life. Here are a few of the emotional reactions recorded by Badawi during his research:

“I cried like mad, shouting ‘You all cheated me'.” (Then the respondent wept silently with a choking voice.)

“I couldn't believe my mother was with them; they all attacked me one early morning while I was still sleeping.”

“Please don't make me remember what happened, I am trying to forget.”

FGM can also have serious psychosexual consequences. It can seriously hamper a woman's ability to achieve orgasm and, in some cases, make sex painful. In addition, the trauma has been known to put some women off sex entirely.

The better efforts over the past few decades of the government, civil society campaigners, religious leaders whose opinion normally counts in this conservative society, the medical profession and feminists have only partially turned the tide and FGM still cuts across social class and religious affiliation, with Muslims and Christians practising it widely.

This raises the question of why, despite such overwhelming condemnation and disapproval, this outdated and cruel practice still survives. Ignorance is one major factor, as many Muslims and Christians – not just in Egypt, but also in the Sudan, eastern, central and western Africa – believe that cutting their daughters is an important religious rite of passage. The ridiculous cherishing of female “chastity” is another reason. Many of FGM's strongest advocates are from insular rural communities or poorer inner city slums and are not educated enough to realise the severe consequences it could have for their daughters nor to resist the peer pressure to conform.

The origins of FGM are shrouded in the mists of time. But the generally accepted theory is that it originated in ancient Egypt. I find this at odds with the empowered status of ancient Egyptian women, unrivalled anywhere in the ancient world and only surpassed perhaps in the 20th century. Perhaps then, too, it was a frowned-upon practice that had survived from a murky tribal past before written history began.

Whatever its origins, FGM has been around for millennia and legislation alone is not enough, as Egypt's own experience attests. The Egyptian government first outlawed the practice in 1959, but relaxed and re-imposed the prohibition in an attempt to stamp out the dangerous operations being conducted in backstreet clinics and at home or in reaction to criticism of the “medicalisation” of the procedure.

So what can be done?

Grassroots work holds out the most promise. One example is what are known as “positive deviants” – those who did not succumb to FGM and are passionately against it. One such woman is Awatef Ramadan, who works for the FGM Abandonment Programme implemented by the Assiut Childhood and Development Association (ACDA) with the support of UNICEF.

“I appeal to future mothers not to subject their children to this operation which is an act of abuse,” she was quoted as saying by UNICEF Egypt. “I tell people that if they really love their daughters they should take good care of them and see that they are well educated. This is something much more important to give a girl and her future husband than circumcising her.”

Her efforts have been so successful that local women put on a play entitled ‘No to FGM' which was seen by large audiences.

And other efforts are slowly paying off. A recent study by Egypt's Ministry of Health and Population found that only half of all girls between the age of 10-18 years have been circumcised.

Another important step is to bring sexual health issues out of the closet in this traditionally reticent society. With religious leaders now openly speaking out against FGM and the superstar status of Egypt's first Islamic TV sex therapist, things seem to be moving in the right direction.

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This article first appeared in The Guardian on 14 August 2007.