The Female Circumcision Controversy. Ellen Gruenbaum
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from outside the frame of meaning of those who do them, to aid medical descriptions for example—cannot be expected to reflect categorizations that are meaningful from any specific cultural perspective. Whether a writer’s typology has three categories or some other number depends on the purposes of the study, whether it is for health education, ethnographic description, or medical analysis. I often use the two common Sudanese terminologies, sunna and pharaonic, because these are significant to the debates about cultural and religious authenticity discussed later, but I also discuss variations and innovations in these surgeries. These two categories parallel Sudanese physician Nahid Toubia’s dichotomous classification of “reduction” operations and “covering” operations (Toubia 1994).
What Should Be the General Term for These Practices?
The term “female genital mutilation” has become more widely accepted since the 1990s. “Mutilation” is technically accurate because most variants of the practices entail damage to or removal of healthy tissues or organs. But for most people, the term “mutilation” implies intentional harm and is tantamount to an accusation of evil intent. Some of my Sudanese friends have been deeply offended by the term, and it is their reaction as much as the connotations of that term that have influenced my preference for the term that is very commonly used when speaking or writing in English: female circumcision. “Female circumcision,” however, echoes the term for the removal of the foreskin in the male, which is generally considered nonmutilating (Toubia 1993:9). The term “female circumcision” is therefore rejected by many people because “circumcision” seems to trivialize the damaging act and the huge scale of its practice.
Neither term—mutilation or circumcision—is a translation of the Arabic word most commonly used for female circumcision in Sudan. Tahur (or its variations such as tahara) is usually translated as “purification” and connotes the achievement of cleanliness through a ritual activity. But in fact there is little about the rather matter-of-fact performance of the surgical act that one would associate with ritual in a religious or mystical sense. Thus using a term that connotes ritual seems both inaccurate and inadequate to the broad range of meanings and contexts of the practices. And some are offended by it, as it could give the impression that practitioners are unreflective or not rational.
“Clitoridectomy” and “infibulation” are somewhat more precise descriptive terms, but a term that encompasses both types of surgeries and other variations is also needed. “Female genital operations” or “genital surgeries” are accurate terms and can be used in some contexts, but they do not adequately differentiate these practices from therapeutic medical surgeries, whereas to call them “traditional female genital operations” evokes the simplified interpretation I challenge in this book. Shortening “female genital mutilation” to the more clinical-sounding FGM is an alternative now used widely by many, including Toubia, writing in the United States for an international audience. She adds, however, the eminently sensible thought that using the terms of reference of the communities where the practice occurs is a “starting point from which to initiate the process of change” (1993:9); she herself varies her terminology in her writing. The term “female genital cutting” (FGC) has been used by some writers and seems to be gaining greater acceptance.
The term “female circumcision” is often used here, despite its clearly euphemistic character, to avoid the connotations of evil intentions or wanton mayhem associated with the term “mutilation.” I am fully cognizant of its inadequacies.
Health Risks
All the forms of female circumcision share certain risks. First, the unhygienic circumstances in which circumcision operations are often carried out, together with the minimal training of many circumcisers, pose serious risks. Infection of the wound is common when unsterilized instruments are used or if cleanliness is not meticulously attended to. Hemorrhage (uncontrolled bleeding) is sometimes difficult to stop if the circumciser has cut too deep. Shock can occur, and septicemia (blood poisoning) can also result. In the days after the surgery, some girls experience retention of urine because of pain, swelling, fear of pain, or obstruction of the urethral opening. Problems such as adhesions of labial tissue (where not entirely removed), vaginal stones, and vaginal stenosis (narrowing) are also reported.
The forms that include infibulation offer additional serious health consequences. Obstruction of menstrual flow can occur in cases in which the scar tissue obstructs the vagina, and an adolescent girl may find menses prevented, with the unsuccessful discharge backing up and distending her uterus. El Dareer described a case in Sudan in which pregnancy was suspected, much to the shame and fear of the girl’s mother, until the true nature of the problem was discovered: the fifteen-year-old girl, who had never menstruated, had such a small opening she had difficulty passing urine and her menstrual discharge had been completely obstructed, perhaps because of vulvo-vaginal atresia (absence of an opening). An incision released the large quantity of fetid blood (1982:37). El Dareer also heard reports of a similar case in which the girl was said to have been killed for the sake of family honor. Even those whose menstrual flow is not obstructed often report painful menstruation, probably not only because of the usual cramps but also because of the tightness of the infibulation and frequent infections.
Later, first intercourse is complicated by infibulation because either painful tearing or unhygienic cutting (by the husband or a midwife called in to assist) commonly occurs. Obstructed intercourse resulting from a tight introitus or painful intercourse (dyspareunia) and chronic pelvic inflammation that might affect penetration or frequency can also result in infertility (Shandall 1967; Verzin 1975; for case descriptions, see El Dareer 1982).
During pregnancy and childbirth, the infibulated opening creates other difficulties. Infections of the vagina or urinary tract may contribute to miscarriage. Chronic pelvic infections are considered a major factor in infertility cases, and infertility is a socially disastrous condition throughout the regions where circumcision is practiced (see Inhorn 1994, 1996). The most severe, life-threatening, long-term complication of infibulation is obstructed labor. Fibrous, inelastic tissues of the vulva may require excessive bearing down during the second stage of labor, exhausting the mother and stressing the infant (El Dareer 1982:38). During childbirth, a midwife must be present to cut the inelastic scar tissue across the vaginal opening when the baby is in position for delivery (crowning) and sew the tissue together again after delivery. This cut is basically an episiotomy that is cut upward (anterior), rather than downward (posterior). Lateral or bilateral episiotomy to widen the vagina is also sometimes necessary (Abdalla 1982:26). Keloid scarring and cysts are not uncommon at the site of the infibulations, which can make the episiotomies themselves, as well as the restitching and healing, difficult. The risks of excessive bleeding and infections from all the cutting needed and the unavailability of medical facilities for emergencies in most rural areas of Africa pose survival risks for mothers. To reduce the risks of childbirth, some women greatly reduce their nutritional intake during pregnancy, a practice that may have the opposite effect.
Delays in the cutting during labor (e.g., if the midwife does not arrive in time or the traditional birth attendant lacks the experience to judge the timing), in addition to posing a risk to the survival of mother and infant, can also cause severe perineal lacerations or damage to vaginal tissue, often resulting in vasicovaginal fistulae, a serious medical problem wherein a passage is created between the vagina and the urinary bladder or other parts of the body cavity, including the rectum (see Shandall 1967, Mudawi 1977, Verzin 1975). For some women the result is a most embarrassing condition rendering her unable to retain urine and producing constant leakage. In rural areas where pads or absorbent cotton are not available in the market or are beyond the means of a family, the woman may be unable to preserve basic hygiene and may suffer the consequence of social avoidance, ostracism, or divorce (El Dareer 1982:38).
Infibulation is also related to an apparently high prevalence of urinary tract and other chronic pelvic infections. If urine cannot be passed easily and there is only a single pinhole-sized opening for both bladder and vagina, some women experience the backing up of urine into the vagina, which is particularly dangerous during pregnancy. One can easily imagine how a woman with such a condition—or any woman who finds it difficult, slow, or painful to pass urine—might be tempted to cut down on her fluids, drinking too little for good health in a hot climate. In many