Northern Ethiopia declare an end to Female Genital Cutting

Female genital cutting (FGC), also known as female genital mutilation (FGM), female circumcision, or female genital mutilation/cutting (FGM/C), is any procedure involving the partial or total removal of the external female genitalia or other injury to the female genital organs "whether for cultural, religious or other non-therapeutic reasons."

• The term is almost exclusively used to describe traditional or religious procedures on a minor, which requires the parents' consent because of the age of the girl.

When the procedure is performed on and with the consent of an adult, it is generally called clitoridectomy, or it may be part of labiaplasty or vaginoplasty. It also generally does not refer to procedures used in sex reassignment surgery, and the genital modification of intersexuals.
FGC is predominantly practiced in Northeast Africa and parts of the Near East and Southeast Asia,although it has also been reported to occur in individual tribes in South America and Australia.Opposition is motivated by concerns regarding the consent (or lack thereof, in most cases) of the patient, and subsequently the safety and long-term consequences of the procedures. In the past several decades, there have been many concerted efforts by the World Health Organization (WHO) to end the practice of FGC. The United Nations has also declared February 6 as "International Day of Zero Tolerance to Female Genital Mutilation".


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

Procedures: World Health Organization categorization

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

Diagram 1:This image shows the different types of FGM and how they differ to the uncircumcised female anatomy.

• Type I

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

• Type II

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

• Type III: Infibulation with excision

The WHO defines Type III FGM as narrowing of the vaginal orifice with creation of a covering seal by cutting and repositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation)." It is the most extensive form of FGM, and accounts for about 10% of all FGM procedures described from Africa.Infibulation is also known as "pharaonic circumcision".
In a study of infibulation in the Horn of Africa, Pieters observed that the procedure involves extensive tissue removal of the external genitalia, including all of the labia minora and the inside of the labia majora. The labia majora are then held together using thorns or stitching. In some cases the girl's legs have been tied together for two to six weeks, to prevent her from moving and to allow the healing of the two sides of the vulva. Nothing remains but the walls of flesh from the pubis down to the anus, with the exception of an opening at the inferior portion of the vulva to allow urine and menstrual blood to pass through; see Diagram 1D. Generally, a practitioner recognized as having the necessary skill carries out this procedure, and a local anesthetic is used. However, when carried out "in the bush", infibulation is often performed by an elderly matron or midwife of the village, without sterile procedure or anesthesia.
A reverse infibulation can be performed to allow for sexual intercourse or when undergoing labor, or by female relatives, whose responsibility it is to inspect the wound every few weeks and open it some more if necessary. During childbirth, the enlargement is too small to allow vaginal delivery, and so the infibulation is opened completely and may be restored after delivery. Again, the legs are sometimes tied together to allow the wound to heal. When childbirth takes place in a hospital, the surgeons may preserve the infibulation by enlarging the vagina with deep episiotomies. Afterwards, the patient may insist that her vulva be closed again.
Women who have been infibulated face a lot of difficulty in delivering children, especially if the infibulation is not undone beforehand, which often results in severe tearing of the infibulated area, or fetal death if the birth canal is not cleared (Toubia, 1995). The risk of severe physical, and psychological complications is more highly associated with women who have undergone infibulations as opposed to one of the lesser forms of FGM. Although there is little research on the psychological side effects of FGM, many women feel great pressure to conform to the norms set out by their community, and suffer from anxiety and depression as a result (Toubia, 1995). "There is also a higher rate of post-traumatic stress disorder in circumcised females" (Nicoletti, 2007, p. 2). 
A five-year study of 300 women and 100 men in Sudan found that "sexual desire, pleasure, and orgasm are experienced by the majority (nearly 90%) of women who have been subjected to this extreme sexual mutilation, in spite of their being culturally bound to hide these experiences."

• Type IV: Other types

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

Reasons for Female Genital Mutilation

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

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

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

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

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

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

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

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

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

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

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

Medical consequence

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

Other serious long term health effects are also common. These include urinary and reproductive tract infections, caused by obstructed flow of urine and menstrual blood, various forms of scarring and infertility.

• Epidermal inclusion cysts may form and expand, particularly in procedures affecting the clitoris. These cysts can grow over time and can become infected, requiring medical attention such as drainage.The first episode of sexual intercourse will often be extremely painful for infibulated women, who will need the labia majora to be opened, to allow their partner access to the vagina. This second cut, sometimes performed by the partner with a knife, can cause other complications to arise.

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

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

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

Sexual effects

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

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

Psychological and psychiatric consequences

In February 2010, a study by Pharos, a Dutch group which gathers information on health care for refugees and migrants,found that many women who have undergone FGC suffer psychiatric problems. This was the first study into the psychiatric and social complaints associated with female circumcision. In the study 66 questioned Dutch African women, who had been subjected to the practice, were found to be "stressed, anxious and aggressive". It also found that they were more likely to have relational problems or in some cases had fears of establishing a relationship. According to the study, an estimated 50 women or girls are believed to be circumcised every year in the Netherlands. The report was published to mark the International day against female genital mutilation.
A study by anthropologist Rogaia M. Abusharaf, found that "circumcision is seen as 'the machinery which liberates the female body from its masculine properties'  and for the women she interviewed, it is a source of empowerment and strength