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MFT 719
Issue Paper – Female Genital Cutting
Jessica Stellberg-Filbert
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Introduction
According to the World Health Organization or WHO (2006), female genital cutting, also
known as female circumcision or female genital mutilation, is a practice deeply rooted in
tradition which is practiced in more than 28 African countries as well as in some countries in
Asia and the Middle East. It is estimated that there are currently 130 million women and girls
who have undergone female genital cutting (FGC) and that there are about 6000 new cases each
day (WHO, 1998). Over 90% of women living in Sudan, Somalia, and Eritrea have been
subjected to the procedure (WHO, 1998).
The World Health Organization (1998) classifies FGC in four different types. These
classifications are currently used and accepted within the literature.
Type I – excision of the prepuce, with or without excision of part or the entire clitoris.
Type II – excision of the clitoris with partial or total excision of the labia minora
Type III – excision of part or all of the external genitalia and stitching/narrowing of the
vaginal opening (infibulation)
Type IV – pricking, piercing or incising of the clitoris and/or labia; stretching of the
clitoris and/or labia; cauterizing by burning the clitoris and surrounding tissue;
scraping of tissue surrounding the vaginal orifice or cutting of the vagina;
introduction of corrosive substances or herbs into the vagina to cause bleeding
or for the purpose of tightening or narrowing it; and any other procedure that
falls under the definitions given above.
The procedure may be carried out at any time across the lifespan, from early infancy to
the time of marriage or death of a husband according to the local custom (Omer-Hashi &
Entwistle, 1995), but occurs most often during puberty (Barstow, 1999). The practice is most
frequently performed by untrained midwives using tools such as kitchen knives, razor blades,
glass shards or even teeth (Barstow, 1999). Usually, the procedure is completed without the use
of anesthetics, antiseptics, analgesics or antibiotics (Barstow, 1999) and the conditions are often
not hygienic (Omer-Hashi & Entwistle, 1995). During the procedure, the girl or woman is
generally restrained by two or more women who are often members of the initiate’s family
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(Barstow, 1999). In the more recent past, FGC carried out by medical personnel in sterile
surgical conditions with local or general anesthesia has become available in more urban areas
(Whitehorn, Ayonrinde, & Maingay, 2002).
The impact of FGC on the health of the individual is dependent on the extent and type of
procedure, the skill of the practitioner, the cleanliness of tools and setting, and the physical
condition of the individual (WHO, 2006). The immediate or short-term health complications
common to all types of FGC are pain, hemorrhage, prolonged bleeding causing shock and death,
local and systemic infection, tetanus, anemia, and gangrene (Williams, Acosta, & McPherson,
1999). The procedure might also facilitate the transmission of HIV due to the use of one
instrument on several girls (Bosch, 2001).
Long-term complications potentially include difficulty in passing urine and urinary tract
infection, pelvic infections (Williams, Acosta, & McPherson, 1999), infertility, keloid scaring,
dyspareunia, sexual dysfunction (Elchalal, Ben-Ami, Gillis, & Brzezinski, 1997), and
complicated obstetric outcomes (WHO, 2006). The psychological effects of FGC are often subtle
and suppressed within the acceptance of social norms (Omer-Hashi & Entwistle, 1995).
FGC is often performed out of tradition or cultural conformity and is believed to preserve
virginity, enhance femininity and marriageability, mark ethnic boundaries (Berggren, Abdel
Salam, Bergström, Johansson, & Edberg, 2004), increase hygiene, aesthetics, fertility, and sexual
pleasure for the husband (Omer-Hashi & Entwistle, 1995). The practice forms a rite of passage
for girls and is part of the socialization process in societies where women’s social acceptance and
access to resources are granted through marriage and childbearing (Bosch, 2001; Williams,
Acosta, & McPherson, 1999).
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FGC has frequently been associated with Islam and many Muslims in practicing countries
hold the belief that genital modification is required by faith (Council on Scientific Affairs,
American Medical Association, 1995). The practice is, however, not specifically tied to any
particular religious faith, as it has been followed by Muslims, Jews, Christians, and members of
indigenous religions and is actually older than any of them (Barstow, 1999; Whitehorn,
Ayonrinde, & Maingay, 2002).
It seems that FGC was designed to control women’s sexuality and reproductive function
and to support the development of patriarchal societies (Omer-Hashi & Entwistle, 1995).
Accordingly, while FGC is commonly perceived by Western cultures to be a ‘foreign’
phenomenon, the surgical removal of the clitoris was a recognized practice in 19th century
Britain and the U.S. in the management of epilepsy, sterility, promiscuity and masturbation
(Kandela, 1999; Omer-Hashi & Entwistle, 1995).
Having become more aware of the practice of FGC through immigration, Western
countries like the U.S., Australia, Canada, Sweden, France, and the UK have adopted legislation
prohibiting the practice as well as any arrangements to have the procedure performed on a child
outside of the country (Allotey, Manderson, & Grover, 2001). Many of these countries have also
developed educational programs with immigrant populations covering health risks as well as the
country’s legislation regarding female genital cutting (Allotey, Manderson, & Grover, 2001).
The UN Declaration of Violence against women includes specific reference to female genital
mutilation (WHO, 1998). Most countries have ratified this convention (Allotey, Manderson, &
Grover, 2001). Also, most of the countries in where FGC is practiced have passed legislation
making the procedure illegal (Gruenbaum, 1991). The literature, however, shows only few cases
worldwide which have been prosecuted (Barstow, 1999).
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In the U.S., female genital cutting has to be attended to not only because of the growing
number of immigrants from practicing countries, but also because of reports that FGC is carried
out within the U.S. as well (Elchalal, Ben-Ami, Gillis, & Brzezinski, 1997). The Center for
Disease Control estimates that 168,000 girls and women are at risk for FGC in the U.S.
(Williams, Acosta, & McPherson, 1999). As the number of affected individuals rises it becomes
increasingly likely that healthcare professionals will see patients and clients with the physical,
psychological, or sexual effects of this procedure (Whitehorn, Ayonrinde, & Maingay, 2002).
Attention paid to the issue of FGC in the public as well as in the medical field has been
problematic. Horowitz and Jackson (1997) found in their study of affected women’s perception
of the care they received at American medical facilities that clinicians’ attitudes toward them
were influenced by perceptions of FGC as ‘barbaric’ or ‘primitive’. The women felt they did not
receive optimal care. The public attention, on the other hand, including graphic representations
and descriptions of the procedure has the potential to leave women feeling that there is complete
disregard for their privacy (Allotey, Manderson, & Grover, 2001). Additionally, many refugee
groups may feel that their ethnic identities are challenged by migration and acculturation
processes. It is, therefore, vital for healthcare professionals to be sensitive to these issues and to
understand how the practice of FGC may serve to secure cultural identity (Whitehorn,
Ayonrinde, & Maingay, 2002).
Summary of Research
Researchers have, in the past, focused their efforts on the demographics such as
prevalence and the physical effects of FGC (Williams, Acosta, & McPherson, 1999). These
studies have been mainly supported and conducted through several international health and aid
organizations such as WHO and UNICEF. The studies which have been conducted outside the
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realm of physical consequences focus on such areas like governmental programs, attitudes about
FGC, and treatment received by immigrant women who had undergone FGC.
Research in these areas showed that the success of programs and legislation about FGC in
immigrant countries has been problematic at best while programs and legislation in countries
where FGC is actually practiced seem to be progressing and empowering for women (Allotey,
Manderson, & Grover, 2001). The same study also showed that women in immigrant
communities in Australia generally did not disagree with the legislation prohibiting FGC but felt
that they should have the right to be re-infibulated after childbirth (Allotey, Manderson, &
Grover, 2001). Nwajei and Otiono (2003) found in their study of circumcised as well as
uncircumcised women at Delta State University, Nigeria that 67% of surveyed circumcised
women would have chosen not to undergo FGC if they would have had a choice. The same
women were, however, more likely than uncircumcised women to want FGC to be performed on
their daughters. With regard to the medical treatment circumcised women receive in immigrant
countries, Berggren, Bergström and Edberg (2006) study about immigrant women in Sweden
that individuals felt patronized, stared at, looked down upon, vulnerable, and different.
Although there are numerous reports and studies on the physical consequences of FGM,
there is a dearth of research on the extensive sexual and psychological consequences of this
practice (Williams, Acosta, & McPherson, 1999). Some of the few studies conducted inquiring
about sexual pleasure and response suggest less damage to both physiological and psychological
response than one might expect (Obermeyer, 1999). There are, however, studies suggesting
otherwise. In their cross-sectional study of 99 women from the Ajengule area of Lagos, Osinowo
and Taiwo (2003) found that uncircumcised women significantly reported better sexual
functioning and marital satisfaction while circumcised women significantly reported higher
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levels of marital instability and lower self-esteem. The researchers concluded that psycho-sexual
dysfunctions were common among circumcised women. Other studies have found that FGC can
cause sexual problems such as dyspareunia, orgasmic delay, anorgasmia (Brighouse, 1992), and
lack of desire (El-Defrawi, Lofty, Dandash, Refaat, & Eyada, 2001). The different outcomes of
these studies pose a warning not to generalize and to treat circumcised women as individuals
with individual outcomes (Allotey, Manderson, & Grover, 2001).
The psychological effects of the practice have also often been neglected (Elchalal, BenAmi, Gillis, & Brzezinski, 1997). These include post-traumatic stress disorder, anxiety,
depression (Elchalal, Ben-Ami, Gillis, & Brzezinski, 1997), feelings of worthlessness and guilt,
reduced social functioning, and suicidal ideation (Whitehorn, Ayonrinde, & Maingay, 2002).
Important Researchers
The topic of FGC is not limited to one specific field of study. It is a topic which
researchers from different areas look at from very different angles. FGC is applicable to the
fields of social science, medicine, women studies, social economics, history, anthropology, and
psychology, just to name a few. Additionally, much of the research done on FGC is supported by
global organizations. Considering these facts, this may be why the literature does not really show
one or two main researchers regarding this topic. The organizations, however, and most
prominently the World Health Organization, have collected most of the basic information. The
categorization of FGC developed by WHO is used throughout the literature and they have
worked to alert public attention to this issue.
Additionally, the contribution of women who have undergone FGC themselves and who
are known in the public cannot be overestimated in relation to public attention. Some of these
contributions include books such as the fashion model Aman’s The Story of a Somali Girl by
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Aman (1995) and Desert Flower: The Extraordinary Journey of a Desert Nomad by Waris Diri
(1995) who is also a model. It would be advisable for practitioners to read these first-hand
accounts to gain a first look at what their clients may have experienced.
Treatment Options
First, it is of the utmost importance that affected women are recognized as a
heterogeneous group with very different needs (Omer-Hashi & Entwistle, 1995). A woman’s
sexuality will be affected by FGC according to the extent of the procedure as well as the degree
to which social messages impacting sexual expression are internalized. However, not all affected
women experience sexual problems (Omer-Hashi & Entwistle, 1995). FGC itself, for example,
does not affect the hormonal stimulants responsible for sexual desire or arousal (Omer-Hashi &
Entwistle, 1995). It is, therefore, advisable not to assume certain outcomes considering the risk
of pathologizing well adjusted individuals who have no complaints stemming from FGC
(Whitehorn, Ayonrinde, & Maingay, 2002). Whitehorn, Ayonrinde and Maingay (2002) also
caution practitioners not to avoid interventions because they fear being perceived as racist but to
approach the subject in a culturally sensitive way.
In the treatment of repercussions from FGC, keeping a close relationship between mental
health professionals, primary care, and pediatric, obstetric, and gynecological services on the one
hand, and immigrant communities on the other is highly important (Whitehorn, Ayonrinde, &
Maingay, 2002). Referral to a physician may, at any rate, be the initial step in treatment, to
ensure that the circumcision has healed properly (Bengston & Baldwin, 1993). Additionally,
education about sexuality, female genital anatomy, and the effects of trauma due to circumcision
may be useful and necessary (Bengston & Baldwin, 1993). Some women may not be aware that
women in other cultures do not undergo FGC and some may not know of the existence of female
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orgasms (Shandall, 1983). Some women may, therefore, experience embarrassment during
medical examinations or intercourse after becoming aware of the differences in appearance of
their genitalia resulting in feelings of anger, guilt, shame, or inadequacy after recognizing a lack
of sexual pleasure (Whitehorn, Ayonrinde, & Maingay, 2002).
Women may have to work through feelings of abandonment, loneliness and betrayal.
When circumcised women move to another country, they may encounter various social situations
which could cause them to question what has been done to them (Bengston & Baldwin, 1993).
Additionally, it is traditionally a female member of the community who carries out the
procedure. This female member may have been closely related to the woman causing the woman
to feel betrayed by someone she trusted and who was supposed to take care of her (Whitehorn,
Ayonrinde, & Maingay, 2002).
FGC has mistakenly been likened to conventional child abuse (Bosch, 2001). There is,
however, at least one main difference. The parents who decide to have FGC performed on their
daughters are likely to honestly believe that they are doing the right thing (Bosch, 2001).
Lightfoot-Klein (1989) pointed out that many parents are unaware of the harmful physical and
psychological repercussions of FGC since most effects of FGC are attributed to other causes. In
practicing communities the intention behind FGC is seen as loving care through making sure that
a girl is marriageable and thereby securing her future (Omer-Hashi & Entwistle, 1995).
Accordingly, the practice even persists among families who feel that FGC should be
abandoned for fear of rendering daughters as outcasts and unmarriageable (WHO, 2006). OmerHashi and Entwistle (1995) advise not to attack parents when they express their concerns about
being unable to have their daughters legally circumcised within the U.S. Instead, practitioners
should attempt to offer an environment for the discussion of the topic and of the pain of loss,
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migration, and displacement (Omer-Hashi & Entwistle, 1995). Female Genital Cutting is,
however, illegal in the U.S. and it can be considered as child abuse when the person at risk is
under-aged. In such cases, marriage and family therapists are required to report the abuse to the
appropriate authorities.
The treatment of the psychological and sexual complications resulting from FGC may
yield some unique difficulties. Some women may, for example, experience pain similar to
vaginismus during intercourse. The problem here is that it is often culturally taboo for a woman
to touch her genitals or use dilators as in some treatments for vaginismus (Omer-Hashi &
Entwistle, 1995). Circumcised women who are sexually active should be advised to use waterbased lubrication to minimize pain and lacerations around the vagina during intercourse (OmerHashi, & Entwistle, 1995).
Deinfibulation – the opening of sutures resulting from infibulation – may be planned
during childbirth or to alleviate physical complications. In these cases, women should be
counseled to abstain until the vulva has healed and should ideally receive education about the
altered appearance and functioning of her genitals which may have a negative impact on her selfesteem (Omer-Hashi, & Entwistle, 1995). Some women may experience increased vaginal
discharge or feel distressed about the unfamiliar sound of urine in a toilet bowl which was
nonexistent before deinfibulation when micturation occurred much more slowly (Allotey,
Manderson, & Grover, 2001). Normalization and validation in these instances may prove to be
helpful in these instances.
Where sexual response is poor due to clitoral excision and/or damage, deinfibulation
alone is likely to have limited impact (Allotey, Manderson, & Grover, 2001). However, Thabet
and Thabet (2003) found clitorolabioplasty to be helpful for the restoration of sexual functioning
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in women who had undergone type II FGC. This possible surgical solution should in any case be
accompanied by counseling which may be helpful in working through issues of anxiety, feelings
of betrayal and the societal messages a woman may have received about sex.
Counseling women who have undergone FGC may draw from several approaches and
include strategies similar to counseling strategies used with survivors of sexual abuse, grief
counseling for the loss of a female body part, cognitive restructuring and correcting negative
self-concepts and sex therapy to adjust sexual practices to be optimal for the woman and her
partner (Bengston & Baldwin, 1993). Support groups may also be helpful (Bengston & Baldwin,
1993). However the counselor and the client choose to work through the repercussions of FGC it
is highly important that the practitioner handles the situation with cultural sensitivity and that he
or she has some knowledge about the practice and the reasons for its perpetuation.
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References
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