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Refaat, A (2009): Medicalization of female genital cutting in Egypt. Eastern Mediterranean Health Journal, Vol. 15, No. 6, 2009: 1379-88
Abstract and Figures
The medicalization of female genital cutting (FGC) has been increasing. This cross-
sectional study estimated the determinants of the practice of FGC among Egyptian physicians. Responses from 193 physicians showed that while 88% of them knew at least one adverse physical or sexual consequence, 18% approved of it, mostly as a religious observation (82%). Almost one-fifth (19%) of physicians practised FGC, mostly due to conviction (51%) or for profit (30%). A negative correlation was found between knowledge of the adverse consequences of FGC and both approval and practice. Cultural influences were the highest determinant (81%) followed by lack of knowledge (35%).
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... However, FGC and its consequences is neither included in the medical schools curricula nor in postgraduate studies. A recent study (Refaat 2007) concluded that about one fifth of the Egyptian physicians practice FGC out of the cultural influence and their lack of knowledge of its consequences rather than financial benefits. Interventions Throughout a decade, I fought the medicalization of FGC using different interventions : ...
Background:
Despite efforts to reduce the burden of female genital mutilation (FGM) in Guinea, the practice remains prevalent, and health care providers are increasingly being implicated in its medicalization. This formative study was conducted to understand the factors that facilitate or impede the health sector in providing FGM prevention and care services to inform the development of health sector-based interventions.
Methods:
Between April and May 2018, a mixed methods formative study was carried out using a rapid assessment methodology in three regions of Guinea-Faranah, Labe and Conakry. A structured questionnaire was completed by one hundred and fifty health care providers of different cadres and 37 semi-structured interviews were conducted with health care providers, women seeking services at public health clinics and key stakeholders, including health systems managers, heads of professional associations and schools of nursing, midwifery, and medicine as well as representatives of the Ministry of Health. Eleven focus group discussions were conducted with female and male community members.
Results:
This study revealed health systems factors, attitudinal factors held by health care providers, and other factors, that may not only promote FGM medicalization but also impede a comprehensive health sector response. Our findings confirm that there is currently no standardized pre-service training on how to assess, document and manage complications of FGM nor are there interventions to promote the prevention of the practice within the health sector. This research also demonstrates the deeply held beliefs of health care providers and community members that perpetuate this practice, and which need to be addressed as part of a health sector approach to FGM prevention.
Conclusion:
As integral members of FGM practicing communities, health care providers understand community beliefs and norms, making them potential change agents. The health sector can support them by incorporating FGM content into their clinical training, ensuring accountability to legal and policy standards, and promoting FGM abandonment as part of a multi-sectoral approach. The findings from this formative research have informed the development of a health sector intervention that is being field tested as part of a multi-country implementation research study in Guinea, Kenya, and Somalia.
Background
Despite the clear stand taken by the United Nations (UN) and other international bodies in ensuring that female genital cutting (FGC) is not performed by health professionals, the rate of medicalization has not reduced. The current study aimed to determine the extent of medicalization of FGC among doctors in Malaysia, who the doctors were who practiced it, how and what was practiced, and the motivations for the practice.
Methods and findings
This mixed method (qualitative and quantitative) study was conducted from 2018 to 2019 using a self-administered questionnaire among Muslim medical doctors from 2 main medical associations with a large number of Muslim members from all over Malaysia who attended their annual conference. For those doctors who did not attend the conference, the questionnaire was posted to them. Association A had 510 members, 64 male Muslim doctors and 333 female Muslim doctors. Association B only had Muslim doctors; 3,088 were female, and 1,323 were male. In total, 894 questionnaires were distributed either by hand or by post, and 366 completed questionnaires were received back. For the qualitative part of the study, a snowball sampling method was used, and 24 in-depth interviews were conducted using a semi-structured questionnaire, until data reached saturation. Quantitative data were analysed using SPSS version 18 (IBM, Armonk, NY). A chi-squared test and binary logistic regression were performed. The qualitative data were transcribed manually, organized, coded, and recoded using NVivo version 12. The clustered codes were elicited as common themes. Most of the respondents were women, had medical degrees from Malaysia, and had a postgraduate degree in Family Medicine. The median age was 42. Most were working with the Ministry of Health (MoH) Malaysia, and in a clinic located in an urban location. The prevalence of Muslim doctors practising FGC was 20.5% (95% CI 16.6–24.9). The main reason cited for practising FGC was religious obligation. Qualitative findings too showed that religion was a strong motivating factor for the practice and its continuation, besides culture and harm reduction. Although most Muslim doctors performed type IV FGC, there were a substantial number performing type I. Respondents who were women (adjusted odds ratio [aOR] 4.4, 95% CI 1.9–10.0. P ≤ 0.001), who owned a clinic (aOR 30.7, 95% CI 12.0–78.4. P ≤ 0.001) or jointly owned a clinic (aOR 7.61, 95% CI 3.2–18.1. P ≤ 0.001), who thought that FGC was legal in Malaysia (aOR 2.09, 95% CI 1.02–4.3. P = 0.04), and who were encouraged in religion (aOR 2.25, 95% CI 3.2–18.1. P = 0.036) and thought that FGC should continue (aOR 3.54, 95% CI 1.25–10.04. P = 0.017) were more likely to practice FGC. The main limitations of the study were the small sample size and low response rate.
Conclusions
In this study, we found that many of the Muslim doctors were unaware of the legal and international stand against FGC, and many wanted the practice to continue. It is a concern that type IV FGC carried out by traditional midwives may be supplanted and exacerbated by type I FGC performed by doctors, calling for strong and urgent action by the Malaysian medical authorities.
Although female genital mutilation/cutting (FGM/C) has declined, it is pervasive albeit changing form among communities in Kenya. Transformation of FGM/C include medicalization although poorly understood has increased undermining abandonment efforts for the practice. We sought to understand drivers of medicalization in FGM/C among selected Kenyan communities. A qualitative study involving participants from Abagusii, Somali and Kuria communities and key informants with health care providers from four Kenyan counties was conducted. Data were collected using in-depth interviews (n = 54), key informant interviews (n = 56) and 45 focus group discussions. Data were transcribed and analyzed thematically using NVivo version 12. We found families practiced FGM/C for reasons including conformity to culture/tradition, religion, marriageability, fear of negative sanctions, and rite of passage. Medicalized FGM/C was only reported by participants from the Abagusii and Somali communities. Few Kuria participants shared that medicalized FGM/C was against their culture and would attract sanctions. Medicalized FGM/C was perceived to have few health complications, shorter healing, and enables families to hide from law. To avoid arrest or sanctions, medicalized FGM/C was performed at home/private clinics. Desire to mitigate health complications and income were cited as reasons for health providers performing of FGM/C. Medicalization was believed to perpetuate the practice as it was perceived as modernized FGM/C. FGM/C remains pervasive in the studied Kenyan communities albeit changed form and context. Findings suggest medicalization sustain FGM/C by allowing families and health providers to conform to social norms underpinning FGM/C while addressing risks of FGM/C complications and legal prohibitions. This underscores the need for more nuanced approaches targeting health providers, families and communities to promote abandonment of FGM/C while addressing medicalization.
Background:
Female genital mutilation/cutting (FGM/C) is a traditional harmful practice that has been prevalent in Egypt for many years. The medicalization of FGM/C has been increasing significantly in Egypt making it the country with the highest rate of medicalization. In this qualitative study, we explored the drivers and motives behind why healthcare professionals perform FGM/C and why mothers rely on them to perform the practice on their daughters.
Methods:
The study drew on a "mystery client" approach, coupled with in-depth interviews (IDIs) and focus group discussions (FGDs) with health care providers (i.e. physicians and nurses) and mothers. It was conducted in three geographic areas in Egypt: Cairo, Assiut and Al Gharbeya.
Results:
Study findings suggest that parents who seek medicalized cutting often do so to minimize health risks while conforming to social expectations. Thus, the factors that support FGM/C overlap with the factors that support medicalization. For many mothers and healthcare providers, adherence to community customs and traditions was the most important motive to practice FGM/C. Also, the social construction of girls' well-being and bodily beauty makes FGM/C a perceived necessity which lays the ground for stigmatization against uncut girls. Finally, the language around FGM/C is being reframed by many healthcare providers as a cosmetic surgery. Such reframing may be one way for providers to overcome the law against FGM/C and market the operation to the clients.
Conclusion:
These contradictions and contestations highlighted in this study among mothers and healthcare providers suggest that legal, moral and social norms that underpin FGM/C practice are not harmonized and would thus lead to a further rise in the medicalization of FGM/C. This also highlights the critical role that health providers can play in efforts to drive the abandonment of FGM/C in Egypt.
Purpose of Review
Female genital cutting/mutilation (FGM/C) performed by health care professionals (medicalization) and reduced severity of cutting have been advanced as strategies for minimizing health risks, sparking acrimonious ongoing debates. This study summarizes key debates and critically assesses supporting evidence.
Recent Findings
While medicalization is concentrated in Africa, health professionals worldwide have faced requests to perform FGM/C. Whether medicalization is hindering the decline of FGM/C is unclear. Factors motivating medicalization include, but are not limited to, safety concerns. Involvement of health professionals in advocacy to end FGM/C can address both the supply and demand side of medicalization, but raises ethical concerns regarding dual loyalty. Ongoing debates need to address competing rights claims.
Summary
Polarizing debates have brought little resolution. We call for a focus on common goals of protecting the health and welfare of girls living in communities where FGM/C is upheld and encourage more informed and open dialog.
Background:
For the last decades, the international community has emphasised the importance of a multisectoral approach to tackle female genital mutilation (FGM/C). While considerable improvement concerning legislations and community involvement is reported, little is known about the involvement of the health sector.
Method:
A mixed methods approach was employed to map the involvement of the health sector in the management of FGM/C both in countries where FGM/C is a traditional practice (countries of origin), and countries where FGM/C is practiced mainly by migrant populations (countries of migration). Data was collected in 2016 using a pilot-tested questionnaire from 30 countries (11 countries of origin and 19 countries of migration). In 2017, interviews were conducted to check for data accuracy and to request relevant explanations. Qualitative data was used to elucidate the quantitative data.
Results:
A total of 24 countries had a policy on FGM/C, of which 19 had assigned coordination bodies and 20 had partially or fully implemented the plans. Nevertheless, allocation of funding and incorporation of monitoring and evaluation systems was lacking in 11 and 13 of these countries respectively. The level of the health sectors' involvement varied considerably across and within countries. Systematic training of healthcare providers (HCP) was more prevalent in countries of origin, whereas involvement of HCP in the prevention of FGM/C was more prevalent in countries of migration. Most countries reported to forbid HCP from conducting FGM/C on both minors and adults, but not consistently forbidding re-infibulation. Availability of healthcare services for girls and women with FGM/C related complications also varied between countries dependent on the type of services. Deinfibulation was available in almost all countries, while clitoral reconstruction and psychological and sexual counselling were available predominantly in countries of migration and then in less than half the countries. Finally, systematic recording of FGM/C in medical records was completely lacking in countries of origin and very limited in countries of migration.
Conclusion:
Substantial progress has been made in the involvement of the health sector in both the treatment and prevention of FGM/C. Still, there are several areas in need for improvement, particularly monitoring and evaluation.
Introduction
Improving healthcare providers’ capacities of prevention and treatment of female genital mutilation (FGM) is important given the fact that 200 million women and girls globally are living with FGM. However, training programs are lacking and often not evaluated. Validated and standardized tools to assess providers’ knowledge, attitude and practice (KAP) regarding FGM are lacking. Therefore, little evidence exists on the impact of training efforts on healthcare providers’ KAP on FGM. The aim of our paper is to systematically review the available published and grey literature on the existing quantitative tools (e.g. scales, questionnaires) measuring healthcare students’ and providers’ KAP on FGM.
Main body
We systematically reviewed the published and grey literature on any quantitative assessment/measurement/evaluation of KAP of healthcare students and providers about FGM from January 1st, 1995 to July 12th, 2016. Twenty-nine papers met our inclusion criteria. We reviewed 18 full text questionnaires implemented and administered to healthcare professionals (students, nurses, midwives and physicians) in high and low income countries. The questionnaires assessed basic KAP on FGM. Some included personal and cultural beliefs, past clinical experiences, personal awareness of available clinical guidelines and laws, previous training on FGM, training needs, caregiver’s confidence in management of women with FGM, communication and personal perceptions. Identified gaps included the medical, psychological or surgical treatments indicated to improve girls and women’s health; correct diagnosis, recording ad reporting capacities; clitoral reconstruction and psychosexual care of circumcised women. Cultural and personal beliefs on FGM were investigated only in high prevalence countries. Few questionnaires addressed care of children, child protection strategies, treatment of short-term complications, and prevention.
Conclusion
There is a need for implementation and testing of interventions aimed at improving healthcare professionals’ and students’ capacities of diagnosis, care and prevention of FGM. Designing tools for measuring the outcomes of such interventions is a critical aspect. A unique, reproducible and standardized questionnaire could be created to measure the effect of a particular training program. Such a tool would also allow comparisons between settings, countries and interventions. An ideal tool would test the clinical capacities of providers in managing complications and communicating with clients with FGM as well as changes in KAP.
Background:
Female genital mutilation (FGM) is a traditional harmful practice that can cause severe physical and psychological damages to girls and women. Increasingly, trained health-care providers carry out the practice at the request of families. It is important to understand the motivations of providers in order to reduce the medicalization of FGM. This integrative review identifies, appraises and summarizes qualitative and quantitative literature exploring the factors that are associated with the medicalization of FGM and/or re-infibulation.
Methods:
Literature searches were conducted in PubMed, CINAHL and grey literature databases. Hand searches of identified studies were also examined. The "CASP Qualitative Research Checklist" and the "STROBE Statement" were used to assess the methodological quality of the qualitative and quantitative studies respectively. A total of 354 articles were reviewed for inclusion.
Results:
Fourteen (14) studies, conducted in countries where FGM is largely practiced as well as in countries hosting migrants from these regions, were included. The main findings about the motivations of health-care providers to practice FGM were: (1) the belief that performing FGM would be less harmful for girls or women than the procedure being performed by a traditional practitioner (the so-called "harm reduction" perspective); (2) the belief that the practice was justified for cultural reasons; (3) the financial gains of performing the procedure; (4) responding to requests of the community or feeling pressured by the community to perform FGM. The main reasons given by health-care providers for not performing FGM were that they (1) are concerned about the risks that FGM can cause for girls' and women's health; (2) are preoccupied by the legal sanctions that might result from performing FGM; and (3) consider FGM to be a "bad practice".
Conclusion:
The findings of this review can inform public health program planners, policy makers and researchers to adapt or create strategies to end medicalization of FGM in countries with high prevalence of this practice, as well as in countries hosting immigrants from these regions. Given the methodological limitations in the included studies, it is clear that more robust in-depth qualitative studies are needed, in order to better tackle the complexity of this phenomenon and contribute to eradicating FGM throughout the world.
Background:
The World Health Organisation (WHO) estimates that 100-140 million girls and women have undergone female genital mutilation or cutting (FGM/C). FGM/C is an ancient cultural practice prevalent in 26 countries in Africa, the Middle East and Asia. With increased immigration, health professionals in high income countries including UK, Europe, North America and Australia care for women and girls with FGM/C. FGM/C is relevant to paediatric practice as it is usually performed in children, however, health professionals' knowledge, clinical practice, and attitudes to FGM/C have not been systematically described. We aimed to conduct a systematic review of the literature to address this gap.
Methods:
The review was conducted according to guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42015015540, http://www.crd.york.ac.uk/PROSPERO/ ). Articles published in English 2000-2014 which used quantitative methods were reviewed.
Results:
Of 159 unique articles, 18 met inclusion criteria. The methodological quality was poor - six studies met seven of the eight quality criteria. Study participants included mainly obstetricians, gynaecologists and midwives (15 studies). We found no papers that studied paediatricians specifically, but two papers reported on subgroups of paediatricians within a mixed sample of health professionals. The 18 articles covered 13 different countries: eight from Africa and 10 from high income countries. Most health professionals were aware of the practice of FGM/C, but few correctly identified the four FGM/C categories defined by WHO. Knowledge about FGM/C legislation varied: 25 % of professionals in a Sudanese study, 46 % of Belgian labour ward staff and 94 % of health professionals from the UK knew that FGM/C was illegal in their country. Health professionals from high income countries had cared for women or girls with FGM/C. The need to report children with FGM/C, or at risk of FGM/C, to child protection authorities was mentioned by only two studies.
Conclusion:
Further research is needed to determine health professionals' attitudes, knowledge and practice to support the development of educational materials and policy to raise awareness and to prevent this harmful practice.
The purpose of this study was to determine if there is a relationship between female circumcision and domestic violence. Results showed that women who suffered from domestic violence and women who experienced genital circumcision shared many low socioeconomic and educational characteristics. Circumcised women were more likely to support continuation of female circumcision, to circumcise their daughters, and to accept the right of husbands to beat their wives.
Female genital mutilation (FGM) is practiced in Egypt, despite its recent ban, generally in rural and uneducated communities, under unsanitary conditions and by non-medical personnel. Immediate and long-term complications are frequent. The aim of this study was to gain insight into what beliefs or knowledge are conducive to supporting FGM.One thousand and seventy university students in Cairo, Egypt were randomly selected. A 32-item questionnaire was used to interview students regarding their knowledge and attitudes toward FGM. Multivariable analyses were performed to find factors associated with being against the abolishment of FGM.The response rate was 95% (n=1020). Twenty-eight percent of the students support FGM. The most significant factors associated with the condoning of FGM were believing FGM has a religious basis (OR=2.53), disagreeing that FGM is a custom with no other basis (OR=2.59), not believing it is harmful (OR=4.11), and ignoring that it is usually followed by complications (OR=5.14).Even in an educated population, a considerable amount of ignorance concerning FGM exists. Widespread education about FGM is important to dispel the myths that surround its practice and to bring the practice to an end. Public Health (2001) 115, 350–355.
In the wake of the death of an 11-year-old girl the Egyptian government has banned any government-affiliated medical staff from performing female circumcision. Egyptian health policy has shifted from trying to control the practice by keeping it under government supervision towards condemnation. In October 1995 the health minister banned female circumcision from being carried out in state hospitals, a direct reversal of a 1994 decree that asked state hospitals to set aside one day a week for performing the procedure. The further restriction follows an incident in July 1996 when an 11-year-old girl bled to death in the rural area of Mansoora after being circumcised by a barber. Female genital mutilation in Egypt changed from an accepted custom to a political hot topic after the news network CNN in September 1994 featured the circumcision of a 9-year-old girl from Cairo. The footage embarrassed Egyptians and fueled an outcry by women's groups and nongovernmental organizations. Statistics compiled in 1994 by Egypt's former ministry of population estimated that between 70% and 90% of Egyptian women were circumcised. But a more recent survey puts the figure even higher, with 97% of women in both rural and urban areas having been circumcised. Circumcisions range from clitoridectomies to almost total removal of the outside genitalia. The practice seems to be rooted in both African tradition and Islamic beliefs, although many Islamic countries do not practice female circumcision. The main motivation seems to be in controlling women's sexual urges, and the belief that circumcision makes a woman more feminine. A university professor of gynecology teaches his medical students that circumcision is healthier for the woman. Most circumcisions in Egypt are performed by barbers or midwives, despite a sporadically enforced law forbidding the operation by anyone but a trained medical staff member. There is a high rate of complications, with some operations leading to infertility. Groups like the Population Council hope that further education and public debate will help to stop the practice.
In July 1996, Egypt's Minister of Health reversed a 1994 ruling of his predecessor that allowed public hospitals to perform female genital mutilation (FGM). 1994 also saw the establishment of a Task Force Against Female Genital Mutilation, which launched a national campaign to reverse this ruling. This campaign included taking the previous Health Minister to court and legally challenging a religious leader who stated that Muslim women should be mutilated. Activists also countered official statistics placing the prevalence of FGM at 50%. A 1995 National Health Survey of 14,000 ever-married women 14-59 years old revealed that 97% had undergone the procedure. These findings were supported by a validation study of 1400 women which showed that 94% were affected. Activists are hopeful because contradictory medical and religious messages are being resolved in favor of banning the procedure, and the media has begun to report deaths from FGM. Challenges remain, however, including a suit filed in court by a group of professors of obstetrics and gynecology who claim that prohibiting the procedure in a clinical setting will result in clandestine operations that endanger women's health. The Egyptian Medical Syndicate, which endorsed the 1994 ruling, has remained silent about the current decree.
Female genital mutilation (FGM)-sometimes locally referred to as "female circumcision"-is a deeply rooted traditional practice that adversely affects the health of girls and women. At present it is estimated that over 120 million girls and women have undergone some form of genital mutilation and that 2 million girls per year are at risk. Most of the girls and women affected live in 28 African countries where the prevalence of female genital mutilation is estimated to range from 5% to 98%. The elimination of female genital mutilation will not only improve women's and children's health; it will also promote gender equity and women's empowerment in the communities where the practice persists. To achieve change will require more planning, and more sustained programmes for its elimination. The political will of governments is essential in order to eliminate this harmful traditional practice and concerted efforts from all concerned are required.
Observations of the types of female genital cutting and possible associated gynecological and delivery complications were undertaken in 21 clinics in rural Burkina Faso and in four rural and four urban clinics in Mali. Women who came to the clinics for services that included a pelvic exam were included in the study, and trained clinic staff observed the presence and type of cut and any associated complications. Ninety-three percent of the women in the Burkina Faso clinics and 94 percent of the women in the Mali clinics had undergone genital cutting. In Burkina Faso, type 1 (clitoridectomy) was the most prevalent (56 percent), whereas in Mali the more severe type 2 cut (excision) was the most prevalent (74 percent); 5 percent of both samples had undergone type 3 cutting (infibulation). Logistic regression analyses show significant positive relationships between the severity of genital cutting and the probability that a woman would have gynecological and obstetric complications.
PIP
This study examines the type of female genital cutting and its possible associated gynecological and delivery complications among females in Burkina Faso and Mali, Africa. Included in the study were women who came to 21 clinics in rural Burkina Faso and in four rural and four urban clinics in Mali seeking medical services that include a pelvic exam. Trained clinical staff observed the presence and type of cut and any associated complications. It was observed that 93% of the women in Burkina Faso and 94% in Mali had undergone genital cutting. The most prevalent type of female genital cutting in Burkina Faso is clitoridectomy, which is 56% among women observed. In Mali, excision was the most prevalent (74%). About 5% of both samples had undergone type 3 cutting, which is the infibulation. Furthermore, there exist a significant relationship between the severity of genital cutting and the possibility of gynecological and obstetric complications.
In recent decades the practice of female "circumcision" has come under intense international scrutiny, often conceptualized as a violation of women's basic right to health. Although the adverse health consequences of female "circumcision" form the basis of opposition to the practice, anti-circumcision activists, as well as many international medical associations, largely oppose measures to improve its safety. The debate over medicalization of female "circumcision" has, up until now, been cast as a moral dilemma: to protect women's health at the expense of legitimating a destructive practice? Or to hasten the elimination of a dangerous practice while allowing women to die from preventable conditions? This paper seeks to re-examine this debate by conceptualizing medicalization of female "circumcision" as a harm-reduction strategy. Harm reduction is a new paradigm in the field of public health that aims to minimize the health hazards associated with risky behaviors, such as intravenous drug use and high-risk sexual behavior, by encouraging safer alternatives, including, but not limited to abstinence. Harm reduction considers a wide range of alternatives, and promotes the alternative that is culturally acceptable and bears the least amount of harm. This paper evaluates the applicability of harm reduction principles to medical interventions for female "circumcision," and draws parallels to other harm reduction programs. In this light, arguments for opposing medicalization of female "circumcision", including the assertion that it counteracts efforts to eliminate the practice, are critically evaluated, revealing that there is not sufficient evidence to support staunch opposition to medicalization. Rather, it appears that medicalization, if implemented as a harm-reduction strategy, may be a sound and compassionate approach to improving women's health in settings where abandonment of the practice of "circumcision" is not immediately attainable.
This study investigated the attitudes of medical students towards female genital mutilation (FGM). The students agreed that it is a priority health problem in the community. As physicians, 61% said they would not perform it on their patients and 17% would join any group fighting this practice. While still students, 52% said they would fight its practice within their families, and 26% planned to initiate action against it. It was not considered a problem at all by 22% of the students surveyed.
This paper examines the association between traditional practices of female genital cutting (FGC) and adult women's reproductive morbidity in rural Gambia. In 1999, we conducted a cross-sectional community survey of 1348 women aged 15-54 years, to estimate the prevalence of reproductive morbidity on the basis of women's reports, a gynaecological examination and laboratory analysis of specimens. Descriptive statistics and logistic regression were used to compare the prevalence of each morbidity between cut and uncut women adjusting for possible confounders. A total of 1157 women consented to gynaecological examination and 58% had signs of genital cutting. There was a high level of agreement between reported circumcision status and that found on examination (97% agreement). The majority of operations consisted of clitoridectomy and excision of the labia minora (WHO classification type II) and were performed between the ages of 4 and 7 years. The practice of genital cutting was highly associated with ethnic group for two of the three main ethnic groups, making the effects of ethnic group and cutting difficult to distinguish. Women who had undergone FGC had a significantly higher prevalence of bacterial vaginosis (BV) [adjusted odds ratio (OR)=1.66; 95% confidence interval (CI) 1.25-2.18] and a substantially higher prevalence of herpes simplex virus 2 (HSV2) [adjusted OR=4.71; 95% CI 3.46-6.42]. The higher prevalence of HSV2 suggests that cut women may be at increased risk of HIV infection. Commonly cited negative consequences of FGC such as damage to the perineum or anus, vulval tumours (such as Bartholin's cysts and excessive keloid formation), painful sex, infertility, prolapse and other reproductive tract infections (RTIs) were not significantly more common in cut women. The relationship between FGC and long-term reproductive morbidity remains unclear, especially in settings where type II cutting predominates. Efforts to eradicate the practice should incorporate a human rights approach rather than rely solely on the damaging health consequences.