ArticlePDF Available

Female genital mutilation. Overview and current knowledge

September 2016
Population 71(2):224-311

Authors:

Armelle Andro

Paris 1 Panthéon-Sorbonne University

Marie Lesclingand

Nice Sophia Antipolis University

Female genital mutilation (FGM), which is any form of non-therapeutic intervention leading to the ablation or alteration of the female genital organs, has adverse health consequences. According to UNICEF, in 2016, more than 200 million women in the world have undergone FGM. This article examines the prevalence of FGM and its variation over time in the different regions of the world, and presents current knowledge of the determinants of the practice and its effects on health and sexuality. Recent public health studies have demonstrated the scale and diversity of the consequences of FGM, and specific medical services have been developed for the women concerned. Available data show that while FGM is well studied in Africa, it remains poorly documented in certain regions of the world. This is notably the case in countries where the practice is clandestine, and in those with immigrant populations from countries where women undergo FGM.

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FEMALE GENITAL MUTILATION. OVERVIEW AND CURRENT

KNOWLEDGE

Armelle Andro, Marie Lesclingand, and Paul Reeve

Translated by Madeleine Grieve

I.N.E.D | « Population »

2016/2 Vol. 71 | pages 224 - 311

ISSN 0032-4663

ISBN 9782733210666

This document is a translation of:

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Armelle Andro et al., « Les mutilations génitales féminines. État des lieux et des

connaissances », Population 2016/2 (Vol. 71), p. 224-311.

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Available online at :

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http://www.cairn-int.info/article-E_POPU_1602_0224--female-genital-mutilation-

overview-and.htm

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How to cite this article :

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Armelle Andro et al., « Les mutilations génitales féminines. État des lieux et des

connaissances », Population 2016/2 (Vol. 71), p. 224-311.

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Armelle Andro* and Marie LesClingand**

Female Genital Mutilation.

Overview and Current Knowledge

AlthoughtheUnitedNationsGeneralAssemblyadoptedaresolutionto

banfemalegenitalmutilation(FGM)inDecember2012,effortstostopthis

formofdiscriminationagainstwomenarestillfarfromuniversal,andthe

numb erofwomenandg irlsconcernedisstillrising.In2016,UNICEFest imates

thatatleast200millionwomenandgirlsalivetodayhavebeensubjectedto

thepracticeworldwide(UNICEF,2016).MostofthemliveinAfrica(in

27countriesspanningthemiddleofthecontinentfromeasttowest,including

Egypt,AppendixTableA.1),inpartsoftheMiddleEastandSoutheastAsia

(Iraq,Yemen,IndonesiaandMalaysia),andincountriesoftheNorthwhere

thereisAfricanimmigration,mainlyEurope,NorthAmericaandAustralia

(UNICEF,2013).

Femalegenitalmutilation,sometimesalsocalledfemalesexualmutilation,

comprise s“allproceduresthatinvolvepart ialortotalremovaloftheexterna l

femalegenitalia,orotherinjurytothefemalegenitalorgansfornon-medical

reasons”(WHO,1997).Theyhaveharmfulconsequencesforsexualand

reproductivehealth.Bythe1990s,femalegenitalmutilation(FGM)had

becomethestandardtermusedbyinternationalorganizationsandbynational

institutionsinthecountriesconcernedbythisissue.Changesinthe

terminologyovertimeanddebatessurroundingthesechangeshavesignalled

paradigmshiftsintheperceptionofthepractice.Theyhaveoccurredin

parallelwiththegrowinginternationalcampaigntoeradicateFGM.The

earlieststudies,conductedfromananthropologicalperspective,focusedon

theritualaspectsofFGM,whichwascalled“femalecircumcision”atthe

time.

(1)

WhentheUnitedNationsrstinvestigatedtheseprocedures,in1958,

theyweredescribedas“customsinvolvingritualpractices”,anexpression

(1) Inreferencetoritesofpassagetoadulthood,whichinmanyAfricansocietiesincludedpractices

ofmaleandfemalecircumcision(Sindzingre,1977).

*UniversitéParis1,CRIDUP(EA134),INED.

**UniversitéCôted’Azur,CNRS,IRD,URMIS,France /INED.

Correspondence:Armelle Andro,UniversitéParis1Panthéon-Sorbonne,CentrePMF,90rue de

Tolbiac,75013Paris,France,email:armelle.andro@univ-paris1.fr



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adoptedbytheWorldHealthOrganizationayearlater(WHO,1959).Inthe

mid-1970s,undertheinuenceoffeministmovements,FGMwascastina

newlight;theparallelwithmalecircumcisionwasrejectedandemphasis

wa spl acedonit sharmfuleffectsonwomena ndg irls’healt h(Hosken,1979).

Thepracticewassubsequentlyaddressedfromahealthandhuman-rights

perspective,anddescribedas“mutilation”(Shell-DuncanandHernlund,

2001).Since2013,UNICEFhasusedtheexpression“femalegenitalmutilation/

cutting”(FGM/C)inEnglishandmutilations génitales féminines/excision

(MGF/E)inFrench. (2)

FGMraisesissuesofdiscrimination,ofhumanrightsandtherightto

health,ofpublichealthintermsofriskpreventionforgirlchildren,andof

sexual,reproductiveandmaternalhealthforwomenwhohaveundergonethe

procedure.Consequently,internationalorganizationsdealingwiththeseissues

havebecomecloselyinvolvedsincethe1990s.ButFGMalsoraisesquestions

abouttherelationsbetweenNorthernandSoutherncountriesinthedenition

ofaninternationaldoctrine,abouttheplaceofminoritiesinmulticultural

societies,andaboutthepertinenceofhegemonicexplanations.FGMremains

adebated,controversialissue.

Forallofthesereasons,thereisnowanabundantscienticliteratureon

FGMspan ningmostdisciplinesofthesocialsciences–a nthropology,sociology,

demography,history,law,politicalscience,psychology,genderstudies,social

work,publichealth–aswellasnumerousarticlesinmedicaljournals(Shell-

DuncanandHernlund,2001).Despitethatoutput,westilllackdataand

thereforeaccurateknowledgeofsomedimensionsofFGM,beitmedicaldata

orinformationabouttheassociateddynamicsofsocialchange.Thisarticle

seekstoreviewthestateofcurrentknowledgeonFGM.

SectionIinvestigatesthesocialandculturalaspectsofthepracticeand

thegradualconstructionofFGMasahumanrightsandright-to-healthissue.

SectionII,moremethodologicalinapproach,examinestheavailabledata

sourcesthatnowenableustoaddressthisformofviolence,whichhaslong

remainedinvisible.SectionIIIdescribestheprevalenceofthepracticearound

theworldanddiscussestheindicatorsusedtomeasureit.SectionIVanalyses

thedynamicsofsocialchangeinacontextofstrongmobilizationtoeradicate

FGM.SectionVpresentsanoverviewoftheconsequencesforthehealthand

sexualityofwomenandgirlswhohaveundergoneFGMandSectionVIlooks

atthevariousmedicalresponses.Initsconclusion,thearticleraisesseveral

pointsfordiscussionwithaviewtollingintheknowledgegapsaboutthis

formofdiscriminationagainstwomen.

(2) “Cutting”isgenerallyconsideredmoreneutralthan“muti lation”andmayalsobeamore

literaltranslat ionoftheexpressionusedinthelanguagesinthecountrie swherethepractice

exists.

A. Andro, M. LescLingAnd

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I. From female circumcision to female genital mutilation

1. An anthropological approach:

understanding the social and cultural aspects

Origins and development

Theexacthistoricalandgeographicaloriginoffemalegenitalmutilation

isunknown.ThehypothesisthatthepracticeoriginatedintheMiddleEast

andtheArabianpeninsulaandwasthencarriedacrosstheAfricancontinent

byArabtradersisnotsharedbyallspecialists(Erlich,1986;Hosken,1982).

WhatdoesseemtobeacceptedisthatFGMisanage-oldpractice,possibly

datingasfarbackasAncientEgypt,(3)whichmayhaveoriginatedinwhatis

nowSud anandEg y pt.Thearchaeologicalcommunityisdividedoverwhether

marksfoundonEgyptianmummiesareevidenceofexcision(Knight,2001).

Therstreferencetoexcision,recordedonpapyrus,datesfromthesecond

centuryBCEinEgypt(Couchard,2003).Latersourcesincludeaccountsof

travellersliketheAncientGreekgeographerStrabo,who,aftertravellingto

Egypt(around25BCE),describedtheoperationasacustomarypractice

(Hosken,1982).

AccordingtoMackie(1996),femalegenitalmutilationspreadfromthe

westernshoreoftheRedSea(inwhatisnowEgypt)toneighbouringregions

ofAfr icatothesouthandwest.Heal soestablishesalinkbetweeninbulation,

(4)

themostinvasiveformofFGM,whichismainlypractisedineasternAfrica

(Eritrea,Djibouti,Somalia,EgyptandSudan),andtheslavetrade,particularly

duringtheperiodofIslamicexpansioninAfrica.ThisextremeformofFGM,

whosenameisderivedfromtheLatinﬁbula (abroochorpin),mayalsohave

beenpractisedonfemaleslavesinAncientRometopreventsexualintercourse

andavoidpregnancies,whichwouldhaverenderedslavesuntforwork

(Hosken,1982).Despitetheuncert aintyaboutit sorigin,theevidencesuggests

thatFGMexistedlongbeforetheemergenceandexpansionofIslaminAfrica,

evenifreligiousjusticationsweresubsequentlyusedtolegitimizeit.Thisis

supportedbythefactthatFGMispractisedincommunitiesofChristians

(Copts,CatholicsandProtestants),Jewsandanimists.Unlikemalecircumcision,

which,inJudaismandIslam,isthesignofacovenantbetweenGod,Abraham

andhisdescendants,thereisnocommandmentonexcisioninthebooksof

themainmonotheisticreligions(5)(Couchard,2003;Thiam,1978).

(3) Femalegenitalmutilationisbelievedtohaveappearedlaterthanmalecircumcision,whichis

attestedinEgyptasearlyasthethirdmillenniumBCE(Erlich,1986).

(4) Excisionofpartoralloftheexternalgenitaliaandstitching/narrowingofthevaginalopening

(Table1).

(5) AccordingtoAwaThiam(1978),theassociationgenerallymadebetweenIslamandexcisionmay

originateinpopularbeliefsaboutthestoryoftheprophetIbrahimaandhistwoco-wivesSarataand

Haidara.TheconictbetweenthetwowomenledSaratatoexciseHaidara.Thesethreecharacters

areknownintheBibleasAbraham,SarahandtheservantHagar.

Female Genital mutilation. overview and Current KnowledGe

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Femalegenitalmutilation(clitoridectomy

(6)

andin bulation)h asalsobeen

historicallypractisedintheWesternworld,evenifnotimposedonwhole

communities.Chastitybelts,(7)aformofmechanicalinbulationasopposed

tothescarringpractisedonfemaleslavesinAncientRome,wereusedinthe

MiddleAges(Hosken,1982).Inthenineteenthcentury,thepathologization

ofcertainsexualpractices,particularlyfemalemasturbation(Laqueur,2005),

ledtothepracticeofsurgicalclitoridectomy,believedtocuretheillsand

deviantbehaviourofwomenwholackedsexualrestraint.Thistypeofsurgery,

mainlypractisedinEuropeinacontextofrepressivemedicalizationofsexuality,

wasrstperformedbyaBritishdoctor,IsaacBakerBrown,whobelieveditto

beaneffectivecureforfemalema sturbat ionandhysteria

(8)

(Sindzingre,1979).

AlthoughBakerBrownwasexpelledfromthemedicalprofessionin1867,in

theUnitedStatesthepracticepersistedintothe1960s(Cutner,1985).

Morerecently,genderreassignmentsurgeryperformedonintersexnewborn

babieshasbeencal ledgenitalmutilationbycampaignersfort her ight softhose

concerned(Löwy,2003).Thistypeofsurgery,rstperformedinthe1950s,(9)

isstillpractisedinsomecountries,includingFrance(Leeetal.,2006).

A rite of passage or a marker of unequal gender relations?

Excisionwasrstdescribedintheanthropologicalliterature,givingrise

tofunctionalistandculturalistanalyseslinkedtoapsychoanalyticalapproach

(Sindzingre,1979).Femalegenitalmutilationwasmainlyseenasariteof

passage,accordingtothethree-phaseinterpretivemodel(separationofthe

individualfromthegroup,marginalizationthenreintegration)establishedin

theearlytwentiethcenturybytheethnographerArnoldVanGennep(1909).

Underthistypeofapproach,whichhasbeenappliedtovariousregionsof

Africa,excisionisconsideredequivalenttomalecircumcisionandisoften

referredtoas“femalecircumcision”toemphasizetheanalogybetweenthe

twopractices,whicharedescribedasmarkersofgender,ageandsometimes

ethnicity(Cartry,1968;Chéron,1933;Colleyn,1975;Droz,2000;Muller,

1993).Thesestudiesprovidedetaileddocumentationofinitiationceremonies,

andadegreeofjustication,byemphasizingthemythicalaspectsofthe

rituals.(10)

Theseapproacheswerechallengedinthe1970s,whenthefeministcampaign

againstexcisionwasatitsmostvigorous.Theequivalencebetweencircumcision

andexcisionwasstronglycontested,alongwiththeircommontheoretical

(6) Excisionoftheprepucewithorwithoutexcisionofpartortheentireclitoris(Table1).

(7) ElizabethGouldDavisdescribeschastitybeltsinThe First Sex,publishedin1972.Onemethod

(whichisamechanicalformofinbulation)involvedpassingringsthroughthelabiamajoraand

fasteningthemwithwireorapadlock(Hosken,1982).

(8) Femalehysteriawasbelievedtostemfromuncontrolledsexualdesire.

(9) TherstsurgicalresponseinthescienticliteraturewasreportedbyHamburgeretal.in1953.

(10) TheexampleoftheDogonmythoforiginalandrogyny,describedbyGriaule(1948),isparticularly

wellknow n.

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framework,andfemalegenitalmutilationwasreframedwithinthebroader

issueofgenderrelations.NicoleSindzingrewastherstinthe1970stoargue

againsttheideaofexcisionasariteofinitiation.Shehighlightedtheasymmetry

inpracticebetweenmalecircumcisionandfemaleexcisionceremoniesdescribed

intheanthropologicalliterature.Firstly,intermsofitsimpactonphysical

integrity,femalegenitalmutilationisnottheequivalentofmalecircumcision.

Furthermore,whilemalecircumcisionceremoniesaredescribedascollective

ritualswithhighsocialvalue,excisionisusuallypresentedasa“shortened”

rite,

(11)

conductedwithinthefamilycircleandcentredontheindividual

(Sindzingre,1977,1979).However,itisprimarilythroughthejustications

forthepractice–aconcerntoeliminatesexualambiguityororiginalandrogyny,

arequirementof“purication”asapre-requisiteformarriageandchildbirth,

andawishtocurbsexualurgesinordertoensureagirl’svirginityandawife’s

delity–thatexcisiontiesinwiththequestionoftherepresentationof

femininityandgenderrelationsmorebroadly.

Withinthevarietyofdiscoursesonfemalegenitalmutilation,itispossible

toidentifyacommonlogicthatnotonlylinksthepracticetoaconcernfor

biologicalreproduction(throughmarriageandprocreation)butalsotoa

concernforsocialreproduction,sincethissexualmarkingalsomarksthe

socialrolesofeachgender.Inmanysocieties,theclitorisrepresentsthe

“malepart”withwhichthefemalesexisendowedatbirth,arepresentation

thatisalsofoundinmythsoforiginalandrogynyorbi sexuality

(12)

(Couc h a r d ,

2003).Removingtheclitoristhusprovidesanecessarymeanstomake

women’sbodiescompletelyfeminine(andexclusivelydevotedtoprocreation),

butalsotoplacetheminasubordinatepositionwithinthemaleorderby

conferringonmentheexclusiveexerciseofmaleauthority,symbolizedby

theclitoris,theequivalentofthepenis

(13)

(Fa inzang,1985).Ta kingupPier re

Bourdieu’sanalysis(1982)ofritesofinstitution,atermhepreferredtorites

ofpassage,excisioncanbeseenasaritualpracticetolegitimizethedifference

betweenthesexesthatunderpinsunequalpowerrelations:excisionis

designedto“de-virilize”thewomaninordertoreduceherpower,whereas

ci rcumcision“re-v ir i lizes”themaninordertoincreasehisauthorit y(Fain z ang,

1985).Thisparadigm,whichdenouncesFGMasviolenceagainstwomenand

incorporatesthepracticeintotheconstructionofunequalgenderrelations,

hasnotbeentotallyeffectiveindeculturalizingthepractice(14)(Boni,20 09).

FGMhassincebeenanalysednotonlyintermsoftheimpositionofpatriarchal

(11) Theexcisionritualisshorter,hasasimplerstructureandfewersymbolicelementsthanthe

malecircumcisionritual(Sindzingre,1977).

(12) Theforeskinofthepenisrepresentsthefemalepartofthemalegenitalia.

(13) Recentstudieshaveshownthat,anatomically,theclitorisisequivalenttothepenis(Foldès

andBuisson,2009).

(14) InFrance,the rstb ookpubl ishe donthei ssuebyAwaThia min1978(La parole aux négresses),

withaprefacebyBenoîteGroult,sparkedwidespreaddebateandwasnotwellreceivedbyAfrican

feminists,whofeltthatsomeofherargumentsamountedtoracistinterference(Boni,2009).

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socialnormsbutalsofromtheperspectiveoftherighttophysicalintegrity

andsexualfreedom(Mbow,1999).

2. The elaboration of an international doctrine against FGM:

human rights and the right to health

On20December2012,theUnitedNationsGeneralAssemblyadopteda

seriesofresolutionstoelimin atepracticesandviolat ion sthatpresentagrave

dangertothehealthofwomenandgirls.Oneoftheveresolutionsonthe

promotionofwomen’srightsfocusesspecicallyonintensifyingglobalefforts

fortheeliminationoffem alegenitalmutilations(A/RES/67/146).Iturgesthe

countriesconcernedtocondemnallharmfulpracticesthataffectwomenand

girls,inparticularfemalegenitalmutilations,andtotakeallnecessary

measures,includingenactingandenforcinglegislation,raisingawareness

andallocatingsufcientresourcestoprotectwomenandgirlsagainstthis

specicformofviolence.Itcallsforprotectionandsupportforwomenand

girlswhoareatriskoforwhohaveundergonefemalegenitalmutilation.

TheresolutionisaddressedtothecountrieswhereFGMistraditionally

practisedandtothecountriesofsettlementofwomenwhohavemigrated

fromthoseregions.

Thisinternationalpolicy,whichhasnowbeenratiedbythe194member

statesoftheUnitedNations,waselaboratedslowlyandinseveralstages.Itis

ba sedont hetr iptychofhumanrights,therighttohealth,andwomen’srights,

principlest hatthem selvesgainedofcialrecognitiont hroughtheinternational

treatiesadoptedinthelatterhalfofthetwentiethcentury.

The stages in the international campaign

TheUnitedNationsCommissiononHumanRightsrstdiscussedthe

traditionalpracticeofFGMin1952.In1958theUNEconomicandSocial

Councilexplicitlyraisedtheis sueofFGMandthehar mitcausesasaproblem

fortheinternationalcommunity(Resolution680BII(XXVI)oftheEconomic

andSocialCouncil:RitualOperations,1958).Atthattime,thepracticewas

approachedprimarily froma culturalistviewpoint.TheWorldHealth

Organizationrefusedtobecomeinvolved,atthetimeconsideringFGMasa

socialandculturalpracticeratherthanahealthissueandthereforeoutsideits

competence(UnitedNations,1959).

In1977theNGOWorkingGrouponTraditionalPracticeswassetup,

openingupadiscussionoftheconsequencesofFGMonthehealthofwomen

andgirls.Thepreviousanthropologicalapproachtothepracticehadeffectively

renderedtheharmfuleffectsofFGMinvisible(Thiam,1978).In1979,the

WHOtookastanceontheissueforthersttimebyinventoryingthemedical

consequencesofFGM.TheWHO’sRegionalOfcefortheEasternMediterranean

inKhartoumconvenedaseminaron“traditionalpracticesaffectingthehealth

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ofwomenandchildren”,attendedbyNGOsanddoctors,atwhichFranHosken

presentedherreportongenitalandsexualmutilationofwomen(WHO,1979).

AttheWorldConferencefortheUnitedNationsDecadeforWomen,held

inCopenhagenin1980,therewasatenseconfrontationbetweentheEuropean

andAfricandelegations.Themajorityofthelatterwerestillcallingforthe

practicetoberecognizedasariteofpassagetoadulthoodonaparwiththe

circumcisionofboys(Sow,1997).However,bytheglobalconferenceonwomen

inNairobiin1985,positionshadchangedandabroaderconsensusbeganto

emerge,wit hrecog nitionthatthepracticewashar m ful.Internationalagencies

becameincreasinglyinvolvedfromthatdateonwards.TheWorkingGroupon

TraditionalPracticesAffectingtheHealthofWomenandChildrensubmitted

it srstreporttotheUNCommissiononHumanRightsin1986(E /CN.4/1986/42).

Inthe1990seffortstobanFGMbecamemorestructured.In1990,theInter-

AfricanCommitteeonTraditionalPractices,setupbyfeministorganizations,

adoptedtheterm“mutilation”,followingUNICEF’slead.

TheUNGeneralAssemblyadoptedtheDeclarationontheEliminationof

ViolenceagainstWomenin1993,whichrefersexplicitlytofemalegenital

mutilation.In1994,theUnitedNationsSub-CommissiononPreventionof

DiscriminationandProtectionofMinoritiesadoptedtherstPlanofAction

fortheEliminationofHarmfulTraditionalPracticesaffectingtheHealthof

WomenandChildren.TheUnitedNations’abolitioniststancewasreiterated

attheInternationalConferenceonPopulationandDevelopmentinCairoin

1994andFourthWorldConferenceonWomeninBeijingin1995.

Underthenewpolicyframework,theWorldHealthOrganizationsponsored

therstjointstatementwithUNICEFandUNFPAin1997,ofcializingtheir

supportforprogrammestopreventandeliminatethepracticeofFGMand

undertakingtosupporttheactionofgovernmentsinthatdirection(WHO,

1997).KnowledgeofandmobilizationontheissuepromptedtheWHOtodraft

thersttypologyofFGMin1997,jointlywithUNICEFandUNFPA(WHO,

1997)(seeSectionI.3).

Internation allegalinstrumentscouldnothavebeendevelopedandadopted

withoutthecampaignsinthecountriesconcerned.Since1984,theroleofthe

Inter-AfricanCommitteeonTraditionalPracticeshasbeenfundamental.The

1981ProtocoltotheAfricanCharteronHumanandPeoples’Rightsonthe

RightsofWomeninAfrica,knownasthe“MaputoProtocol”,isalegal

instrument,adoptedbyconsensusin2003bytheheadsofstateoftheAfrican

Union.Article5oftheprotocolexplicitlyprohibitsandcondemnsFGMand

otherharmfulpractices.Itcallsonthesignatorystatestotakemeasuresto

developpublicawareness,topasslegislationbackedbysanctionstoprohibit

FGM,tosupportvictimsofharmfulpracticesandtoprotectwomenwhoare

atrisk(zerotolerancetoFGM).In2008,aninter-agencystatementledbythe

WHO,UNICEFandUNFPAsetforththeinter n ationalpositiononerad icating

femalegenitalmutilation(WHO,2008).

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From controversy to globalization of the issue

Thegradualemergenceofaconsensusaroundaninternationalpolicy

onFGMhasbeenhamperedbythecompeting discoursesofvarious

internationalbodies.ElizabethBoyle(2005)pointedoutthat,withinthe

UnitedNationsitself,therecognitionoftheuniversalrightsofwomenand

therighttob odilyintegr ityha slongcompetedw iththeprinciplesofsovereign

autonomyandrespectfort raditionsandfamilytra nsmission.Intheend,the

formerprinciplestookprecedenceintheelaborationoftheinternational

doctrineonFGM.

Thedoctrineisunderpinnedbytwolegalprinciples:therighttohealth

andhumanrights.Someauthorshavedescribedthe“uneasyalliance”between

humanrightsandtherighttohealthindiscussionsofFGM(Gruenbaum,

2001;HernlundandShell-Duncan,2007).Itwasthroughemphasisonthe

healtheffectsofFGMthatthepracticecametobeseennotintermsofaritual

ofsocializationbutasagraveviolationofthephysicalintegrityofthewomen

subjectedtoit,thusprovidinggroundsforanalysisfromahuman-rights

perspective(Abusharaf,2006).However,thehealthapproachhasalsoproved

counter-productive,becauseopponentscitealackofmedicalevidence

(Obermeyer,1999)andbecauseofthemedicalizationofFGMprocedures

(SectionVI).

Moreover,themotivesbehindtheeffortsofinternationalfemin istmovements

tobanthepracticeh avelongcomeundersu spicion.Theinter nationalcampaign

hastoooftenpor trayedA fricanwomenasenduringthecustomwit houtresisting

it,eventhoughitendangersthelivesoftheirdaughters.Thisreductionist

representationhasledtotheinternationalcampaignbeingperceivedasracialist

andpost-colonial,takingtheformofacrusadebyfeministsfromtheNorth

thathasovershadowedtheinitiativesemanatingfromthesocietiesconcerned

(Boddy,2007;LaBarbera,2009).

Perceptionsofthepracticehavenonethelesschangedconsiderablysince

theturnofthetwenty-rstcentury.FGM,perceivedasanexclusivelyAfrican

probleminthetwentiethcentury,hasnowbecomeaglobalissue,fortwomain

reasons.Firstly,recentstudiesshowthatFGMisalsotraditionallypractised

inotherregionsoftheworld,wheretheprevalenceofthephenomenonwas

previouslyunknown,andinsomecountriesoftheMiddleEast

(15)

andAsia,

(16)

particularlyIndonesia(UNICEF,2015).Secondly,theglobalizationofmigration

owsandthesettlementinNortherncountriesoffamiliesfromregionswhere

FGMistraditionallypractisedhaveleddestinationcountriestoconsiderthe

practiceasadomesticpublichealthissue(Bell,2005;JohnsdotterandEssen,

(15) WiththeexceptionofIraqandYemen,wherenationalsurveydatawerecollected(Appendix

TableA.1),studiesmentiontheexistenceofthepracticeinminoritycommunitiesinotherMiddle

Ea ste rncount r ie s(Om an, Jord a n, Sy r ia,Un it edA rabEm irate s,SaudiAra bi a), butt her ei sin suf cient

datatoevaluateprevalence(AlsibianiandRouzi,2010;UNICEF,2013,2016;WADI,2010).

(16) RecentlypublishedsurveyreportsmentiontheexistenceofthepracticeinIndonesia(UNICEF,

2015;Budiharsanaetal.,2003)andMalaysia(Isaetal.,1999;Rashidetal.,2009).

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2010).ThisnewdimensionofFGMhasraisedquestionsaboutthepossible

existenceofthepracticeinyetmorecountriesandabouttheimplicationsof

perpetuatingorabandoningthepracticeinthecontextofmigration.

Legislative developments

Inthecountriesoforiginandofdestination,legislationonFGMhas

graduallymovedinlinewiththeintensiedinternationalandregionalefforts

tobanthepracticesincethe1990s(Toubia,1993).InDakar,in2005,the

AfricanParliamentaryConferenceadoptedaresolutioncallingonstatesto

enactlawstobanFGM.(17)

Ofthe30countrieswiththehighestprevalenceofFGM,25havepassed

decreesorlawsonthepracticeinrecentdecades.Inthevastmajorityof

countries,lawshavebeenpassedsincethelate1990s;(18)in15countries,they

wereintroducedinthe2000sand2010s(AppendixTableA.2).Thescopeof

thislegislationvariesconsiderablyacrosscountries

(19)

andthedivergence

betweeninternationalstandardsandlocalsocialnormsmakesitdifcultto

enforce(Boyleetal.,2002).

Theintroductionofalegislativeframeworkinthecountriesoforigin

hasbeensimultaneouswithsimilardevelopmentsinthecountriesof

immigration.TherstdestinationcountriestocriminalizeFGM,inthelate

1970sandearly1980s,wereFrance(1979),Sweden(1982)andtheUnited

Kingdom(1985).TheUnitedStates,Canada,AustraliaandNorwaypassed

legislationinthe1990s,andtheotherEuropeancountriesinthe2000s

(Boyle,2005).SomeEuropeancountrieshavespeciclawsonFGM,while

others(suchasFrance)haveincludedFGMintheirlegislationonchildabuse

andmut ilat ion(EuropeanInst ituteforGenderEqualit y,2013).Almostallof

thelawsincludeaprincipleofextra-territoriality,whichmakesitpossible

toprotectgirlswhohabituallyresideoutsidetheircountryoforigin;young

girlsareoftenathigherriskofundergoingFGMduringtemporarystaysin

theirparents’homecountry.Theselegislativeprovisionshaveledto

prosecutionsinsixEuropeancountries,althoughformanyyearsFrancewas

theonlycountrytohavetakencasesofFGM(20)tocourt(Boyle,2005;Leye

etal.,2007).InFrance,FGMhasb eenacri minaloffencesince1979(Articles

222.08,222.09and222.10oftheCriminalCode);in2006,thestatuteof

limitationswasextendedtoallowvictimstolifeacomplaintupto20years

aftertheirmajorityatage18.

(17) http://www.ipu.org/splz-e/dakar05/declaration.htm

(18) Exceptfortwocountries,GuineaandtheCentralAfricanRepublic,wherelawswereintroduced

inthemid-1960s(AppendixTableA.2).

(19) InMauritania,thepracticeisonlyprohibitedinpublicmedicalfacilitiesandonlyonminors

(likewiseinTanzania).Attheotherendofthespectr um,inKenya,anamendmentpassedin2001added

anext ra-te rritor ialcl aus e,provi din gfor pr ose cutionofact scomm itted outsideKe ny a( UNICEF,2010).

(20) By2012,42caseshadbeentriedinsixEUcountries,ofwhich29inFrance.Thersttrialin

Francetookplacein1979(Leyeetal.,2007).

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3. Classifying the different types of mutilation

WiththehelpofdatafromtherstDemographicandHealthSurveys(DHS)

tocompriseaspecicmoduleonFGM,theWHOdevelopedtherstclassication

offemalegenitalmutilationin1995(WHO,1996).Includedintherstinter-

agencystatement(WHO,1997),thetypologyoffersacommonframeworkfor

identifyingandclassif y ingdifferentt y pesofmuti lation(Table1).Thepurpose

oftheinternationaltypologyis(1)toproposeatoolforstudyingtheconsequences

ofmutil ation,(2)toen ablemoreaccurateestimate softhetrendsi nprevalence

Table 1. WHO classiﬁcation of FGM (1997 and 2007 revision)

Modiﬁed WHO typology of FGM, 2007 WHO typology, 1997

Type I: Partial or total removal of the clitoris and/

or the prepuce (clitoridectomy).

When it is important to distinguish between the

major variations of Type I mutilation, the

following subdivisions are proposed:

Type Ia: Removal of the clitoral hood or prepuce

only;

Type Ib: Removal of the clitoris with the prepuce.

Type I: Excision of the prepuce, with or without

excision of part or the entire clitoris.

Type II: Partial or total removal of the clitoris and

the labia minora, with or without excision of the

labia majora (excision).

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 II: Excision of the clitoris with partial or total

excision of the labia minora.

Type III: Narrowing of the vaginal oriﬁce with

creation of a covering seal by cutting and

appositioning the labia minora and/or the labia

majora, with or without excision of the clitoris

(inﬁbulation).

When it is important to distinguish between

variations in inﬁbulations, the following

subdivisions are proposed:

Type IIIa: Removal and apposition of the labia

minora;

Type IIIb: Removal and apposition of the labia

majora.

Type III: Excision of part or all of the external

genitalia and stitching/narrowing of the vaginal

opening (inﬁbulation).

Type IV: All other harmful procedures to the

female genitalia for non-medical purposes, for

example: pricking, piercing, incising, scraping

and cauterization.

Type IV: Unclassiﬁed: pricking, piercing or incising of

the clitoris and/or labia; stretching of the clitoris

and/or labia; cauterization by burning of the clitoris

and surrounding tissue; scraping of tissue

surrounding the vaginal oriﬁce (angurya cut) or

cutting of the vagina (gishiri cuts); 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 deﬁnition given above.

Source: WHO, 2008.

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andpractices,(3)tofacilitatediagnosisbyhealthcarepractitionersduring

medicalex aminations,and(4)toprov ideaframeworkofreferencefort helegal

treatmentoftheissue.

The current WHO classication

In1997,theWHOproposeditsrstclassicationbasedonfourtypesof

practiceaccordingtotheanatomicalextentofthecutting(Table1)(WHO,

1996,2008).Afterthetypologywasrelea sedin1997,expertspointedoutsome

limitations,namelythattheproposedcategoriesover-simpliedthediversity

ofactualpractices.Theclassicationwasrevisedin2007,basedonthe

conclusionsofagroupofexpertscommissionedbytheWHO.Thecategories

inthe1997classicationwereamendedslightlyandsubdivisionswerecreated

tocoverthewiderangeofproceduresmorefully.Theinter-agencystatement,

publishedjointlybyeightUNagenciesin2008,indicatesthatFGMencompasses

arangeofpracticesthat,whiletheyallviolatetheintegrityofthefemale

genitalia,arenonethelessextremelyvaried(WHO,2008).

Since2008,theWHOhasthereforerecommendedthatfemalegenital

mutilationbeclassiedintofourmaintypes,denedonthebasisofthe

procedureperformedatthetimeofthemutilation:TypeI,oftendescribedas

clitoridectomy(partialortotalremovaloftheclitoralhoodandclitoralglans);

TypeII,oftencalledexcision(removaloftheinnerl abi aandtheclitoris);Type

III,oftencalledinbulation(narrowingofthevaginaloricebystitchingthe

outerlabiaovert heopening,withorwit houtremova loftheclitoris);andType

IVwhichincludestheotherlesscommontypes(incising,cauterization,

scarring).TypesI,IIandIIIcanbefurtherdividedintosub-types(Table1).

ThemostcommonformsofmutilationareTypesIandII.InWestAfrica,the

mostcommonformofFGMisTypeII,whereastherarerTypeIIIismainly

foundineasternAfrica(UNICEF,2013)(SectionIII.2).

The limitations of the classication

Untilthe2000s,specicmodulesonFGMinsocio-demographicsurveys

(SectionII.1)explicitlyaskedwomenaboutthetypeofFGMtheyhadundergone

byinvitingthemtochoosefromoneofthethreemaintypesdenedbythe

WHO (excision,clitoridectomyand infibulation).(21)Thequalityofthe

informationgatheredwasquestionable,however.Severalstudiescomparing

thedatacollectedfromrespondentswiththedatafromclinicalexaminations

revealedconsiderablediscrepancies,particularlyintheregionswhereTypeIII

FGM(inbulation)istraditionallypractised,andwherethewomenoften

reportedhavingundergoneTypeIorII(Elmusharafetal.,2006b).Inpractice,

(21) Inmostofthesurveysconductedinthe1990s,thefemalerespondentswereaskedtoindicate

whichofthethreemaintypesofFGMhadbeenperformedonthem.Inthelate1990s,twosurveys

(Côted’Ivoirein1998-1999andNigerin1998)modiedtheirapproachbyaskingtherespondents

todescribewhathadbeendonetothem;theiranswersweresubsequentlyclassiedunderoneofthe

threetypesdenedbytheWHO(Yoder,AbderrahimandZhuzhuni,2004).

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thewomendonotalwaysknowwhichproceduretheyhaveundergoneand

areunabletogiveapreciseanswer.Moreover,thetermsusedbyrespondents

todescribethetypesofmutilationperformedonthemvaryacrosscontexts

anddonotalwaysconformtotheWHO’sphysiologicaldescriptions(Yoderet

al.,2004).Startinginthe2000s,thequestiononFGMwasrewordedinthe

DemographicandHealthSurveys(DHS)andtheMultipleIndicatorCluster

Surveys(MICS),primarilyinordertomapprevalenceofthemostinvasive

procedure,i.e.TypeIII.(22)Therstclinicalstudiesperformedinthe1990s

showedthatTypeIIIFGMwasassociatedwithmoreserioushealthrisks,

particularlyobstetriccomplications(Obermeyer,1999,2003;WHOStudy

GrouponFemaleGenitalMutilationandObstetricOutcome,2006).Although

theWHOclassicationappearstobeunsuitableforsurveysbasedonself-

reporting(SectionII.3),itisstillusefulforclinicalstudies(Yoder etal.,2004).

TheclassicationdevelopedbytheWHOin1997wasrevisedin2007

becausethecategoriesinitiallyproposedweretooreductionistandfailedto

capturethediversityofprocedures(Table1).Thetypologyisconstructedon

thebasisoftwofactors:theextentoftissueremovalandthetypeofprocedure

performedatthetimeofthemutilation(cuttingand/orstitching).Itinvolves

assessingtheamountoftissueremovedbytheFGMpractitioner,whichvaries

byregion,ethnicgrouporagewhentheFGMwasperformed;andreporting

whetherthevulvawa sst itchedornot.Thehypothe sisofacaus alli nkbetween

theextentoftissueremovalandtheseverityofconsequencesiscentraltothe

WHOtypology.Itisnotalwaysveried,(23)however,andtheseverityof

consequences(particularlypsychologicalandsexual)canvarywithsocio-

demographiccharacteristics(ageandmaritalstatus).Moreover,thetypology

doesnotconsiderthesocialandhealthenvironmentinwhichthewomen

concernedarenowliving.Amongmigrantwomen,thequalityofobstetric

healthcareatthetimeofchildbirthinthecountryofimmigrationcanminimize

theconsequencesofFGM;thesituationisverydifferentincountrieswhere

littleperinatalcareisavailable(Andro etal.,2014;Essénetal.,2005;Zenner

etal.,2013).

II. Data sources

Therstquantit ativemedicaldataonFGMappearedi ntherepor tpresented

byFr anHoskenatt heWHO’sr sti nternat ion alseminaronFGMinKhartoum

in1979(Hosken,1978,1979).Thatwastherstattempttomeasurethe

prevalenceofthepracticeinAfrica.QuantitativedataonFGMwascollected

regularlyinthecountriesoforiginfromthe1990s,sothatthereisnowa

(22) ThequestionintroducedintotheDHS-MICSquestionnairewas:“Wasyourgenitalareasewn

closed?”(AppendixdocumentA).

(23) Insometypesofinbulation,theclitorisisleftintact,unlikeinTypesIorII,whicharethought

tohaveagreaterimpactonsexualsensitivity(Nouretal.,2006).

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subst antialbodyofreliablestatist ics.Ther stl arge-scalesurveyswereconducted

atnationallevelinthecountrieshistoricallyconcernedbythepractice

(27countriesinAfricaandtwocountriesintheMiddleEast)(24)aspartof

variousinternationaldemographicsurveyprogrammes(DHSandMICS)

(AppendixTableA.1).Severalotherstudie sattesttothepracticeofFGMamong

minoritygroupsinotherpartsoftheworld,forexampleinpartsofMalaysia

(Isaetal.,1999;Rashid etal.,2009)andColombia(UNFPA,2011),butthere

isinsufcientdatafromrepresentativesurveystoreliablyassessprevalenceat

thisstage.PrevalenceInIndonesiahasbeenestimatedforthersttimeusing

datafromahealthsurveyconductedin2013onarepresentativesampleof

households(UNICEF,2015).

Lastly,FGMpersistsamongmigrantpopulations,particularlyinEurope,

NorthAmericaandAustraliaandinsomeMiddleEasterncountries.(25)Data

collectiononFGMincountriesofimmigrationismuchmorerecent(2000s)

andisneitherstandardizednorgeneralized,asitisinthecountriesoforigin.

Socio-demographicsurveyswereconductedintwoEuropeancountries(France

andItaly)inthelate2000s.Despitethelackofsurveydata,prevalencecanbe

estimatedindirectly(SectionIII.1).

Clinicalstudies,conductedincountriesoforiginandcountriesof

immigration,canbeusedtoassesstheconsequencesofFGMonhealth,in

particularonwomen’sreproductivehealth.

1. Socio-demographic surveys

In the countries of origin

Datainthecountriesoforigincomefromtwomainsources:Demographic

andHealthSurveys(DHS)(26)andMultipleIndicatorClusterSurveys(MICS)

organizedbyUNICEF.(27)TherstmodulespecicallyonFGMwasi ntroduced

intheindividualquestionnaireforwomenintheDHSconductedinNorth

Sudanin1989-1990,thenextendedtotheDHSconductedinalloftheAfrican

countriesconcernedbythepractice(Côted’Ivoire,1994;Egypt,1995;Eritrea,

1995;Mali,1995-1996;CentralAfricanRepublic,1994-1995).TheFGMmodule

isnowincludedintheDHSin25countries(YoderandWang,2013).Sincethe

2000s,theMICShavealsobeenusedtogatherdataonFGMin17countries,

includingseven(28)forwhichnodatahadpreviouslyexisted(UNICEF,2013).

(24) YemenandIraq.

(25) ThatappearstobethecaseinSaudiArabia,wherethepracticeisobservedinpopulationgroups

th atori ginatefromYeme na ndneigh bourin gc ou ntr ies int he HornofAfri ca(A l sibia nia ndRou zi,2010).

(26) TheDemographicandHealthSurveyprogrammewasstartedin1984

(http://dhsprogram.com/ What-We-Do/Survey-Types/DHS.cfm).

(27) TheMultipleIndicatorClusterSurveyprogrammewasintroducedinthemid-1990stomonitor

thesituationofwomenandchildren:http://www.unicef.org/statistics/index_24302.html

(28) Djibouti,2006;TheGambia,2005-2006;Guinea-Bissau,2006;SierraLeone,2005-2006;Somalia,

2006;Chad,2000;Togo,2006.

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TheIndonesiansurveyconductedon30,000householdsin2013wasnota

DHS-orMICS-typesurvey,andthequestionsonFGMonlyconcernedgirls

agedunder12(UNICEF,2015).Inthe30countrieswhereFGMisconcentrated

(allinAfrica,exceptforIraq,YemenandIndonesia),89nationallyrepresentative

surveysareavailable,coveringa25-yearperiod(1989-2014).Foralmostseven

intenofthesecountries,thedatafromatleastthreesurveysareavailable

(AppendixTableA.1).

ThemoduleonFGMintheDHSquestionnairesisstandardized,although

therearesomevariantsindifferentcountriesandsomechangessincetherst

versioninthe1990s(Yoderetal.,2004;YoderandWang,2013).Themodule,

administeredtofemalesurveyrespondentsaged15-49,isintroducedbyalter

questiononknowledgeofFGM.Themoduleconsistsofthreesetsofquestions

(AppendixTableA.1):

• Therespondent’sownFGMstatus:cutornot,typeofcutting,circumstances

ofcutting(agewhencutandpersonwhoperformedtheprocedure);

• TheFGMstatusoftherespondent’sdaughter(s)(agedunder15):(29)cut

ornot,typeofcutting,circumstancesofcutting(samequestionsasfor

themother)andintentionforthefuture(askedofwomenwhohadat

leastonedaughteragedunder15whohadnotbeencutatthetimeof

thesurvey);

•Perceptionsandattitudes:benetsofcutting/notcutting,reasonsfor

thepractice,attitudetocontinuingorabandoningthepracticeand

perceptionofitsimpactonhealth.

Inthe2000s,thequestionsonperceptionsandattitudeswerealsoincluded

intheindividualque stionnaireadministeredtomalesurveyrespondent s.Since

2010,theDHSandMICShaveusedasimilarquestionnaire.Somequestions

wereremoved(thehealthimpactofFGM,respondents’intentionsfortheir

daughters),whileotherquestions(cutornot,typea ndcircumstance sofcutting)

wereextendedtoincludealldaughtersagedunder15livingwiththeirmother

(YoderandWang,2013).

Thedatawereanalysedtomeasuretheextentofthepracticebycalculating

thepercentagesofwomenandgirlswhohaveundergoneFGMineachcountry.

Theseindicatorsareconsideredtobeprevalenceratesintheepidemiological

sense.Theprevalenceofaconditionatapointintimetisthenumberofcases

(individuals)withthecondition(here,hav i ngundergoneFGM)relativetothe

totalpopulation(here,thetotalnumberofwomen).Thismeasure,basedon

representativesamples,isthenextrapolatedtoestimatethetotalnumberof

womenandgirlswhohaveundergoneFGM(YoderandKhan,2008;Yoderet

al.,2013).Furthermore,matchingthedataonFGMagainstthewomen’ssocio-

(29) Before1999,thequestionsabouttherespondent’sdaughterswereonlyaskedabouttheeldest

daughter.Between2000and2010,ifthewomanreportedthatatleastoneofherdaughtershadbeen

cut,thequestionswereonlyaskedaboutthedaughtermostrecentlycut.Since2010,thequestions

havebeenaskedaboutalldaughters.

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demographiccharacteristicsgivesanindicationofthecharacteristicsand

determinantsofthepractice,whichvaryfromonecountrytoanother,orwithin

thesamecountry,byethnicity,educationallevel,income,etc.Thevariations

inprevalencebyagegroupandtheexistenceofdatacollectedatdifferent

dates

(30)

makeitpossibletoasse sstrendsint hephenomenonovert ime.Lastly,

informationaboutperceptionsandattitudes(collectedfrommenandwomen)

givesanideaoft herationalesunderpinningtheaba ndonmentorperpetuation

ofFGMinthesecountries.Sincethelate1990s,theresultsoftheDHSand

MICShavebeenpresentedinseveralreportsthatgiveadetailedoverviewof

thepracticeinthemostaffectedcountries(Carr,1997;UNICEF,2005,2013;

Yoderetal.,2004,2013;YoderandKhan,2008;YoderandWang,2013).

In countries of immigration

InEuropeandNorthAmerica,FGMconcernsonlyaspecicpartofthe

population,namelywomenwhooriginatefromat-riskcountries.FGMisnota

socialnormintheseregions;onthecontrary,itisadeviant,clandestinepractice,

whichisprohibitedandhasbeenagainstthelawforseveraldecades.Incountries

ofimmigration,therearenonationallyrepresentativesurveyswithaDHS-type

moduleonFGM.Inthe2010s,twosocio-demographicsurveysexplicitlyon

FGMwereconductedintwoEuropeancountries:Italy(FarinaandOrtensi,

2014b;Ortensietal.,2015)andFrance(Androetal.,2009).Thetargetpopulations

weremigrantwomen(anddaughtersofmigrantsintheFrenchsurvey)andthe

surveyswereconductedinasexualandreproductivehealthframework.The

Italiansurveywasperformedinasingleregion,Lombardy,onarepresentative

sampleof2,011migrantwomenandgirlsaged15-49;theFrenchsurveywas

conductedinveregions(31)onasampleof2,882migrantwomenaged18and

over.Thetargetpopulationofbothsurveys(womenhavingundergoneorat

riskofundergoingFGM)issmallandhardtoreach.Applyingsurveyprotocols

designedtoovercometheseproblems(MarpsatandRazandratsima,2012),

thewomenweresurveyedathealthcentres(familyplanningcentres,mother-

and-babycentres,gynaecologicalappointmentsinhospitals,etc.).Theywere

selectedusingtime-locationsampling(TLS),

(32)

combinedwithrespondent-

drivensamplingfortheItaliansurvey.(33)Inbothsurveys,questionsaboutthe

FGMstatusofthewomensurveyedandtheirdaughterswereaskedusingthe

moduleonFGMfromt heDHS.TheFrenchsur veywasal sodesignedasacase-

(30) Sixcountrieshavesurveysthatcanbeusedtomonitorthetrendinprevalenceoveraperiodof

atleast15years:Côted’Ivoire,Egy pt,Mali,CentralAfricanRepublic,SudanandYemen.

(31) The sewereveofth en ineFr en chreg io nsident ie da sha vin gthel arges tp opula tions of wome n

fromcountrieswhereFGMispractised:Île-de-France,Provence-Alpes-Côted’Azur,Nord-Pas-de-

Calais,PaysdelaLoireandHaute-Normandie(Androetal.,2009).

(32) First, thelocationsattendedbythepopulationofinterestandthetimesatwhich they

attendareinventoriedtocreateasurveybase.Arandomsampleoftimesofdayateachlocation

(location×

time)isthentaken,followedbyasampleoftheindividualswhoattendthelocationsat

thesampletimes(MarpsatandRazandratsima,2013).

(33) Snowballsampling.

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cont rolstudytomeasuretheef fectsofFGMont hehealt hofthewomenconcerned

(inthesamewayasclinicalsurveys).Italsocontainedamoduleonreconstructive

surgery,(34)whichisavailableinFrance;areconstructivesurgeryprogramme

wassetupbyaFrenchurologistinthe1990s,coveredbyFrenchpublichealth

insurancesince2004(SectionVI.3).

2. Clinical surveys: measuring the medical consequences of FGM

Therehavebeenmanyclinicalsurveysofthemedicalconsequencesof

FGM,butqualityisvariable.Whiletheoldestonesdatefromthe1960s,the

numberofstudiesincreasedsharplyinthe2000s.Inarecentreview,Rigmor

Bergandcolleagues(2014)inventoriedmorethan180studiesoftheconsequences

ofFGMinEnglish-languagebibliographicaldatabases.Thereviewprobably

underest imatesthetotalnumberofstudie s,someofwhichmaynotbei ncluded

inthosedatabases.Thatneverthelessleavesabodyofalmost140quantitative

studies,

(35)

coveringaroundtenwomenforthesmallesttoseveralthousand

forthelargest(FilloandLeone,2007).Mostofthesur veysexaminedifferences

inhealthriskbetweenwomenwhohaveundergoneFGMandotherwomen

livinginthesameenvironment,ordifferencesinhealthriskbytypeofFGM

performed(Almroth,Elmusharafetal.,2005;Breweretal.,2007;Elmusharaf,

ElhadiandAlmroth,2006;Kaplanetal.,2011;LarsenandOkonofua,2002;

Morisonetal.,2001).Theotherclinicalstudie sfocuseit heronseriesofwomen

whoattendmedicalconsultations,

(36)

ortaketheformofcros s-sectionalhealth

surveys,describingthestateofhealth(assessedbymedicaldiagnosisorself-

reporting)atatimetofasampleofwomenhavingundergoneFGM.Thereare

alsosomecase-controlstudies,whichofferamorereliableandstatistically

accurateassessmentoftheadditionalhealthrisk(AlsibianiandRouzi,2010;

Androetal.,2014).

Thequalityofthestudiesvarieswiththemethodologyused,thesample

sizeandtheprecisionofthequestionnairesorformsusedtodiagnosethe

medicalconsequencesofFGM.However,accordingtoarecentevaluation,

morethanhalfofthemproducereliableorrelativelyreliableresults(Berget

al.,2014;BergandUnderland,2013).Mostofthestudieswereconductedin

thecountriesoforigin,inparticularincountriesintheHornofAfrica.Since

2010,severalclin icalstudie shavebeenconductedincount r iesofimmigration

(Abdulcadir etal.,2011;Andro etal.,2014;Vloeberghsetal.,2012;Wuestet

al.,2009).Lastly,giventheover-representationofcountriesfromeasternAfrica

(34) Thismodulewasdividedintotwosections:therstsectionwasadministeredtoallwomenwho

reportedhavingundergoneFGMandfocusedonawarenessofreconstructivesurgeryandinterestin

it;thesecondsectionwasonlyadministeredtowomenwhohadundergonereconstructivesurgery

(orwhohadrequestedit)(Androetal.,2009).

(35) Theothersareindividualcasestudiesofferingadetailedanalysisoftheconditionofoneperson.

(36) InventoriesofconditionsordisordersdiagnosedinasampleofwomenhavingundergoneFGM,

mostofwhomwereinterviewedatthetimeofmedicalconsultations,butwithoutcomparisonwith

acontrolgroup(Akotiongaetal.,2001;Al-Hussaini,2003)

A. Andro, M. LescLingAnd

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inclinicalresearch,mostofthesurveysareofwomenwhohaveundergone

inbulation.Theclinicalsurveys,whichhaveenabledtheWHOtodene

policypositionsandrecommendations,mostlyinvestigatetheconsequences

ofFGMonsexualandreproductivehealth:theyconsiderboththeimmediate

andlong-termimpact,focusingonobstetric,gynaecological,sexualand

psychologicalconsequences(SectionV).

3. Limitations and biases of self-reported data

Uncertainty linked to self-reporting

FGMstatusrecordedbysocio-demographicsurveysisbasedonself-

reportingbythewomensurveyed.Itisassumedthatthewomenareawareof

theircondition,andareabletoanswerthequestionswithoutfear.Therst

assumption,thatcutwomenhaveanaccurateawarenessoftheirstatus,isnot

alwaysveried.Severalstudies,whichcomparewomen’sself-reportswiththe

ndingsofclinicalexaminationsbyhealthcarepractitioners,revealdiscrepancies

betweenthetwo:whileonestudy,conductedintheGambia,foundadifference

ofonly3%betweenthetwotypesofdata(Morisonetal.,2001),studies

conductedinTanzaniaandNigeriafoundalargerdivergence(Klouman etal.,

2005;Snowetal.,2002).Researchersattributethesedifferencestotwomain

factors:rstly,somewomen,whounderwentFGMatveryyoungages,arenot

fullyawareoftheirstatus,andsecondly,somemoresupercialtypesofFGM

donotnecessarilycauseavisiblealterationoftheexternalgenitaliaandare

notdiagnosedbyclinicalexamination.

Thesameobservationshavebeenmadeinmigra ntpopulat ions,particularly

intheFrenchsurvey,whichincludedrespondents’self-reportsanddiagnoses

byhealthcarepractitioners(withthewomen’spriorconsent):amongthe

respondentsforwhombothtypesofdataareavailable(60%ofthesample),

thematchwasaround90%.Morethanhalfofthedifferencecouldbeattributed

tothecli nici an’sfailuretoe stablishad iagnosis(theclinicianan swered,“Don’t

know”).Incountriesofimmigration,suchdiagnosticfailuresarelinkedtoa

lackofmedicaltraininginidentifyingFGM(Androet al.,2009).Interviews

havealsorevealedthatitisfairlycommonforwomentodiscovertheirFGM

statusonlywhentheybecomesexuallyactive,andinsomecasesonlywhen

theygivebirth(Andro etal.,2010).

Under-reporting linked to the legislative context

Anotherunder-reportingbia smaybelinkedtolegislativechangesincertain

countries(SectionI.2).AlongitudinalstudyconductedinnorthernGhanain

1995and2000assessedtheconsistencyofwomen’sself-reportsovertime:

15%ofthewomensurveyedonbothdatesgavedifferentanswers,withthe

majorityofthatgroupreportinghavingundergoneFGMintherstsurveyin

1995,andofnothavingundergoneFGMinthesecondsurveyin2000.The

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researchersattributedthedifferencetoalegislativeeffect:therstlaw

criminalizingFGMinGhanawasintroducedin1994andwasfollowedby

awareness-raisingcampaigns(Jacksonet al.,2003).(37)Areluctancetoreport

havingundergoneFGMinanenvironmentwherethepracticehasbeenbanned

hasalsobeenobservedinotherAfricancountrieswheredatahavebeencollected

ondifferentdates.

(38)

Fromthemid-2000s,wheninternationalandAfrican

bodiesintensiedtheircampaignagainstFGM,

(39)

severalDHSsurveysrecorded

unexplaineddecreasesintheprevalenceofFGMinsomeagegroups,which

didnotseemtoreectrealdeclinesbutwereprobablytheresultofunder-

reportingbythewomensurveyed(UNICEF,2013).

Suchunder-reportingisevenmorelikelyinmigrationcontexts,particularly

insurveysofmigrants’descendantswithoriginsinanat-riskcountry.In

France,forexample,wherethepracticeofFGMhasnosociallegitimacyin

themainstreampopulationandwherethelegislationisparticularlystrict

(SectionI.2),itisdifcultforwomenbornorraisedinFrancetoreporthaving

undergoneFGMandevenmoredifcultforthemtoreportFGMperformed

ontheirdaughters.Itisthereforeimportanttoconsiderthecontextsinwhich

thequestionsonFGMareasked,inordertoadaptthesurveyprotocols

accordinglyandtoincreasethenumberofdatasources(Askew,2005).

III. Genital mutilation around the world

1. Measuring the scale of the phenomenon

In1979,t heHoskenreportpre sentedtherstmeasuresofthetot alnumber

ofgirlsandwomenwithFGMontheAfricancontinent.Intheabsenceof

nationalsurveydata,thecountryprevalencerateswereestimatedonthebasis

ofcasest udies(40) andthendi rectlyappliedtothenumberofwomen(41)ine ach

country.Althoughthisrstattemptatestimatingprevalencewasrelatively

cr udeanditsmet hodologyopentocrit icism,itscontextwasagrowingmovement

againstFGMandnascentinternationalawarenessofthemagnitudeofthe

phenomenonanditshealthimpacts.Whenthereportwaspublishedin1979,

FranHoskenestimatedthattherewerearound80millionwomenwithFGM

(37) Accordingtothestudyauthors,therstconvictionsofcircumcisersin1996raisedawareness

ofthe1994law.

(38) TheintervalbetweentwoDHSsurveysisusuallyveyears.Wewouldthereforeexpectthe

prevalenceobservedinthe20-24agegroupondatettobesimilartothatobservedinthe25-29age

groupondatet+5.

(39) TheMaputoProtocol(ProtocoltotheAfricanCharteronHumanandPeople’sRightsonthe

RightsofWomeninAfrica),whichcallsonAfricancountriestotakestepstoeliminateFGMand

otherharmfultraditionalpracticesagainstwomen,cameintoforcein2005(SectionI.2).

(40) Thedatafromthe26countriesincludedinthereportwerenotdrawnfromrepresentative

surveys,andwerehighlydisparate(Hosken,1982).

(41) Thenumbersofwomenwerenotdrawnfromcensusdata,butcorrespondedtohalfthetotal

populationineachcountry,assumingthatthisistheproportionofwomeninthepopulation.

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ontheAfricancontinent(Hosken,1979).In1995thedatawereupdatedon

theba sisofpopulationgrowthrate s,bringingt heestimatednumberofwomen

andgirlswithFGMto150million(Hosken,1995;Table2).Until2015,allthe

publicationsofinternationalorganizations(UNFPA,WHO,UNICEF)andall

publishedresearchonFGMreferredtototalnumbersofbetween100and

140mill ionwomenandgirlsw ithFGMintheworld,withoutclearlyspecif y ing

themethodologyusedtoarriveatthesegures(Yoder etal.,2013).Avery

recentUNICEFpublication(early2016),whichaddsIndonesia,evaluatesthe

numberat200million.

AsmoreDHSandMICSsurveysareconductedinthecountriesoforigin

andnewdataareobtainedontheprevalenceofthispracticeinbothwomen

aged15-49yearsandtheirdaughtersagedbelow15years,estimateswillbe

increasinglyreliableandwelldocumented.Intheabsenceofdocumented

prevalencerates,estimateshavealsobeenproducedincountriesofimmigration

usingindirectmethods.

Direct estimates on the basis of socio-demographic surveys

In1997,aninitialest imate(Table2)est ablishedonthebasisofDemographic

andHealt hSur vey ssuggestedthattherewere30mill ionwomenandgirlsw ith

FGMinsevencountries(Carr,1997).Tenyearslater,aggregateddatafrom

27Africancountriesledtoanestimateof92million(YoderandKhan,2008).

In2013,theestimatednumberinAfricaandtheMiddleEastwas125million

(UNICEF,2013;Table2).InFebruary2016,UNICEFpublishedanewestimate

Table 2. Some estimates of the number of women with FGM in countries

where survey data are available

Reference Number of women

and girls (million) Region Type of data used

Hosken, 1979 80 26 African countries Case studies

Hosken, 1982 84 26 African countries Case studies

Hosken, 1995 150 26 African countries Case studies

Carr, 1997 30 6 African countries (Côte d’Ivoire,

Egypt, Eritrea, Mali, Central African

Republic, Sudan) and Yemen DHS surveys

Yoder and Khan,

2008 92 27 African countries DHS and MICS

surveys and US

Census Bureau data

Yoder et al., 2013 100 27 African countries and Yemen DHS and MICS

surveys and US

Census Bureau data

UNICEF, 2013

(a) 125 27 African countries, Yemen and

Iraq

DHS and MICS

surveys and US

Census Bureau data

UNICEF, 2016 200 27 African countries, Yemen, Iraq,

and Indonesia

DHS and MICS

surveys and US

Census Bureau data

(a) This estimate, which features in the 2013 UNICEF report (p. 22), is based on the methodology developed by

Yoder and colleagues (also published in 2013), with the addition of data from Iraq and using the most recent

survey data. These notably include DHS surveys carried out in the early 2010s (the estimate of Yoder and colleagues

had drawn on data from the the 2000s only).

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oftheaffectedpopulationofwomenandgirlsaroundtheworld,updating

estimatesestablishedin2013(onthebasisofpopulationgrowthrates)and

addingthepopulationofwomenandgirlswithFGMinIndonesiaonthebasis

ofdatacollectedin2013fromgirlsbelowage12.TheUNICEFestimate

increasedfrom125millionto200million.Thislargedifferenceislinked

notablytothedemographicweightofIndonesia(255millioninhabitantsin

2015),whereanestimatedoneintwogirlsorwomenhaveundergoneFGM

(UNICEF,2016).

Thecalculationmethodusedinthemostrecentandpreci selydocumented

estimates(2008and2013)isbased,rst,ontheproportionofwomenwith

FGMineachcountry(42)ascalculatedonthebasisofDHSandMICSsurvey

data,andsecond,onthenumbersofwomenineachcountryasindicatedby

theUSCensusBureau.

ThesamplepopulationsoftheDHSandMICSsurveysincludeonlywomen

aged15-49.Aninitialdirectestimatecanbeestablishedbyapplyingthe

prevalenceratesprovidedbydemographicsurveystototalnumbersofwomen

aged15-49,breakingdowntheratesintove-yearagegroupsasprevalence

canvaryacrossagegroups(SectionIV.2).Forwomenaged50oraboveandfor

girlsaged10-14(forwhomprevalencedataarelacking),theratesfortheclosest

knownagegroup(respectively,45-49yearsand15-19years)areapplied

(AppendixgureA.1).

Indirect estimates in the absence of survey data

Incountriesofimmigration,directestimatesareimpossiblefortworeasons:

therstisthelackofrepresentativesurveysatthenationallevelcomparable

totheDemographicandHealthSurveys(DHS)whichincludeamoduleon

FGMforthewholefemalepopulationresidinginthesecountries(Section

II.1).(43)Thesecondresidesinthedi fcultyofidentif y i ngtherelevantpopul ation,

notablyincountrieswithnopopulationregister.Thispopulationconsistsof

immigrantwomen(bornabroad)fromcountrieswhereFGMistraditionally

practiced,andwomenbornincountriesofimmigrationtoatleastoneparent

fromoneofthesecountries.Fortherstgroup,dependingonthecountry,

publicstatisticaldatabycountryoforiginisnotalwaysavailable(notablydue

tothesmallnumbersofrelevantindividuals),andsomemayalsohavea

residencystatusthatmakesidenticationverydifcult(undocumented

individuals,refugees,asylumseekers).Womeninthesecondcategorycanonly

beidentiedusingknowledgeoftheirparents’countryofbirth,aquestion

thatisrarelyaskedinlargenationalsurveys(Simon,2012).

Thereisthusnoclearlydened,homogeneousmethodologyforestimating

prevalenceinthevariouscountriesofimmigration.TheEuropeanParliament

(42) Calledtheprevalenceorprevalencerateofthepractice.

(43) TheViragesurveyongenderviolencecurrentlyunderwayinFranceisthersttoaskthequestion

ofFGMstatusinageneralpopulationsurvey.

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resolutionof24March2009onCombatingFemaleGenitalMutilationinthe

EU (European Parlia ment, 2009)e stimated th att here were around

500,000womenw ithFGMlivingintheEU,andt hat180,000gi rlswereatrisk

ofFGMeachyear.Themethodologyusedtoarriveatthesegureswasnot

specied(Leyeetal.,2014).Whilethereiscurrentlynowaytocalculatean

overallestimate(likethoseestablishedforthecountriesoforigin),estimates

producedusingindirectmethods–basedontheextrapolationofobserved

prevalenceincountriesoforigin–areavailableforanumberofcountries

(Table3).(4 4)

Thisi ndirectestim ationmethodconsistsofapplyingtheobservedprevalence

incountriesoforigintothepopulationsofwomenandgirlsfromat-risk

countries(AppendixgureA.2).Itsdetailsvarydependingonthepublic

statisticaldatathatareavailableforeachcountry(Leyeetal.,2014).InEurope,

estimateswereest ablishedbeginningin2005,notablyinthewesternEuropean

countrieswiththelargestpopulationsofimmigrantsanddescendantsof

immigrantsfromat-riskcountries(Belgium,France,Germany,Italy,andthe

UnitedKingdom).Inthelate2000s,ontheinitiativeoftheEuropeanInstitute

(44) Theseestimatesareavailablefor13countriesintheEuropeanUnion(Leyeetal.,2014)and

fortheUnitedStates(Jonesetal.,1997;PRB,2013).Toourknowledge,indirectestimatesarenot

availableforotherpossiblyaffectedcountriessuchasCanadaandAustralia.

Table 3. Estimates of the total number of women with FGM

in countries of immigration

Reference Number of women

and girls with FGM Country Types of data used

Andro and Lesclingand,

2007 53,000

(a) France Survey combined with census

(Étude de l’histoire familiale [family

history survey]) and DHS-MICS

Ministero delle Pari

Opportunita, 2009 35,000 Italy Population register, residence

permit data, and DHS-MICS

Hänselmann et al., 2011 24,000 Germany Population census and DHS-MICS

Dubourg and Richard, 2011 13,000 Belgium

National population register,

seekers, birth records, and

DHS-MICS

PRB, 2013 507,000 United States Census and DHS-MICS

Exterkate, 2013 29,000 Netherlands Census, register of female asylum

seekers, DHS-MICS

Macfarlane and Dorkenoo,

2014 137,000 England and

Wales Population census, birth register,

and DHS-MICS

(a) The estimate was for adult women only.

Note: For complete country-by-country documentation on European countries, see the website of the European

Institute for Gender Equality (EIGE): http://eige.europa.eu/gender-based-violence/literature-and-legislation

Sources: Andro and Lesclingand, 2007; Dubourg et al., 2011; Exterkate, 2013; Leye et al., 2014; Macfarlane

and Dorkenoo, 2014; Ortensi et al., 2015; PRB, 2013.

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forGenderEquality(EIGE),agroupofEuropeanexpertsundertookamajor

reviewofexistingworkonFGMinEurope,andnot ablyofestimatesproduced

inindividualcountries(EuropeanInstituteforGenderEquality,2013).Generally,

therststepconsistsinidentifyingthereferencepopulation,denedasall

womenandgirlswhocomefromthe30countrieswherethepracticeofFGM

existsandisdocumented,orwithatleastoneparentfromoneofthosecountries

(SectionII.1),bymeansofdifferentsources(populationcensus,population

registers,generalpopulationsurveys,registersofrefugeesorasylumseekers,

etc.).TheprevalenceratesprovidedbytheDHS/MICSsurveysarethenapplied

tothisreferencepopulation(AppendixgureA.2).Dependingonthevariables

availableinagivencountryofimmigration,theseratesmaybebrokendown

byage,levelofeducation,andageatarrivalinthecountry(Leyeetal.,2014).

Theseindirectestimatesaresubjecttoanumberoflimitationsandbiases.

Theidenticationoftherelevantpopulationdependsonthedataavailable

fromcensuses,theexistenceofapopulationregister,andeaseofaccessto

registersofasylumseekersandbirths.Theheterogeneityofsourcesmakesit

difculttouseacommonmethodologyindifferentcountries.Moreover,

dependingonthehistoryofmigrationowstoeachcountry,thepresenceof

asecond,orevenathirdgenerationalsoimplieslocallyspecicdenitionsof

the“at-riskpopulation”.Formigrantwomen,thedenitionislargelyshared,

namelyallwomenborninoneofthe30countrieswherethepracticeisidentied

andprevalencehasbeenmeasuredusingDHSandMICSsurveys.Forsubsequent

generations,thedenitionofwomenwith“origins”inat-riskcountries(those

bornincountriesofimmigration,butwithparentageinanat-riskcountry)

canvary:forexample,havingoneorbothparentsborninanat-riskcountry.

However,asmentionedabove,informationonparents’countryofbirthisrarely

available(Simon,2012).

Otherlimitationsorbiasesoftheseindirectestimatesarelinkedtothe

methodofextrapolation,i.e.theapplicationofprevalencesmeasuredinthese

countriesoforigintothepopulationidentiedasat-riskincountriesof

immigration.AswewillseeinSectionIII.2,thepracticeofFGMvarieswith

ethnicity(orgeographicorigin),levelofeducation,placeofresidence(urban/

rural),income,andage(inthecountrieswherethepracticeisdecreasingover

thegenerations),amongotherfactors.Whileitisgenerallypossible,when

calculatingestimatesi ncountriesofimmig ration,toapplyobservedprevalence

ratesfromcountriesoforiginbyageandlevelofeducation(variablesthatare

alsoavailablefromsurveysincountriesofimmigration),itisrarelypossible

todosoonthebasisofethnicoriginusingpublicstatisticaldataintheNorth.

Andyetprevalencecanvarywidelybyethnicgroupwithinagivencountryof

origin:inSenegal,whilethenationalprevalenceofFGMis26%,itispractically

non-existentamongtheWolof(1%)a ndSerer(2%),butveryw idespre adamong

thePoular(55%),Diola(52%),Soninke(65%),andMandingo(82%)ethnic

groups(DHS-MICSSenegal,2010-2011).Theapplicationofameannational

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prevalencebycountryoforigincanthusleadtosubstantialunder-orover-

estimation,dependingonthemigrants’ethnicorigin.(45)

Moreover,itisdifcultfortheseindirectestimatestofactorintheeffects

ofmigrat ionitself.Otherstud iesh avedemon stratedthatthemigrantpopulation

isnotsocio-demographicallyrepresentativeofthepopulationthatremainsin

thecountryofor igin(Ma ssey,1998),andalsothatmig rationcanh aveaneffect

ontheactualpracticeofFGM,notablyamonggirlswhomigratedinearly

childhoodandwhohadnotundergoneFGMatthetime.Furthermore,protection

againstFGMhasbecomeanadmissiblereasonforseekingasyluminseveral

Europeancountries.Since2009,theUnitedNationsHighCommissionfor

Refugeeshasrecognizedthatawoman’sorgirl’sfearofbeingsubjectedtoFGM

constitutesoneofthevegroundsforrecognitionasarefugee(“membership

inaparticularsoci algroup”).

(46)

However,accordingtoarecentUNHCRstudy,

thenumberofwomenclaimingasylumonthebasisofariskofmutilation

remainsquitelow(UNHCR,2013).(47)

Otherrecentstudieshaverenedthemethodologyforestimatingnumbers

ofwomenwithFGMbytakingintoaccountthelargestpossiblesetof

sociodemographicvariablesinordertobettercharacterizethemigrant

population(Ortensietal.,2015).Theyalsoapplydifferenthypothesesdepending

onageatarrivalinthecountryofimmigration,assuming,forexample,that

girlswhoarrivebeforetheageof15yearsarenotsubjecttothesamerisksas

thosewhoarriveafterthisage,whoweremoreexposedtotheserisksintheir

countryoforigin(AndroandLesclingand,2007;Exterkate,2013).

Andnally,themethodofextrapolationisparticularlydifculttoapply

totherst-generation(andevensecond-generation)descendantsofi mmigrants.

Inadditiontoselectioneffects,itmaybeassumedthatimmersionand

socializationinthedestinationsocietyleadtotheprogressiveabandonment

ofFGM(SectionIV.1).Butquant itativedat aontheabandonmentorp erpetuat ion

ofthispracticeinthecontextofmigrationaregenerallylacking,asidefrom

ItalianandFrenchsociodemographicsurveys(AndroandLesclingand,2008;

FarinaandOrtensi,2014b).Intheabsenceofsuchdata,theapplicationof

prevalenceratesobservedincountriesoforigintothedaughtersofmigrants

isahighlyapproximatesolutionatbest.

(45) However,ethnicoriginalonedoesnotsufcetoexplaindifferencesinprevalence.Theresultsof

theDHSandMICSsurveysalsoshowthatprevalencecanvarywithinasingleethnicgroupdepending

ontheindividuals’nationality(UNICEF,2013).

(46) Thisreasonisinvokedmoreandmorefrequentlywhendeterminingrefugeestatus,asstates

haverecognizedwomen,families,tribes,membersofparticularprofessions,andhomosexualsas

constituting“acertainsocialgroup”inthesenseofthe1951Convention.Thesocialgroupinour

casecanbedenedbroadlyas“womenandgirls”,ormorenarrowlyas“womenbelongingtoan

ethnicgroupthatpracticesFGM”(UNHCR,2009).

(47) InFrance,forexample,theUNHCRestimatesthatin2011,amongthe2,735asylumapplications

ledbywomenfromcountrieswhereFGMispracticed,670weredirectlygroundeduponariskof

mutilation(UNHCR,2013).

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2. Current situation in the countries of origin

Prevalence rates by country and region

TheprevalenceofFGMvarieswidelyacrossthe30countries(almostall

inAfricaandtheMiddleEast)whereitismostcommon(Figure1).Theycan

begroupedintofourbroadcategoriesbyprevalencerate:(1)countrieswhere

thepracticeisnearlyuniversal,withprevalenceof80%orhigher;(2)countries

wherethemajorityofwomenundergogenitalmutilation,butprevalenceis

moremoderate(50-79%);(3)countrieswhereonlyaportionofthepopulation

(25-49%)isconcernedbythispractice;and(4)countrieswhereFGMisa

minoritypractice,withprevalencebelow25%.InAfrica,thepracticeextends

throughawidecentralbandrunningacrossthecontinentfromwesttoeast,

withprevalenceparticularlyhighinalargeportionofwestAfrica(Mali,Guinea,

SierraLeone,BurkinaFaso,andMauritania)andtheeasternmostpartofeast

Africa(Somalia,Djibouti,Eritrea,Egypt,andSudan).FGMisnotpracticedin

theMaghreb,southernAfrica,oralargeportionofcentralAfrica(Figure1).

Figure 1. Prevalence of FGM in Africa

INED

051A16

Kenya

Dijbouti

Nigeria

Niger

GhanaTogo

Côte-

d'Ivoire

Liberia

Sierra Leone

Burkina

Faso

Mali

Mauritania

Somalia

Tanzania

Uganda

Eritrea

Central African

Republic

Chad

Benin

The Gambia

Senegal

Cameroon

80-100%

50-79%

25-49%

Below 25%

Zero prevalence

Guinea

Ethiopia

Egypt

Guinea-Bissau

South

Sudan

Sources: Most recent DHS and MICS surveys (Appendix table A.1).

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Thesenationalprevalenceratesarenotthebestwaytoapproachthisvery

long-standingpractice,historicallymorecommoninsomesocietiesthanin

others.Evenincountrieswithveryhighnationalprevalence,FGMisabsent

orrareincertainpopulat ions.

(48)

Within-countrycontrastsbyregionofresidence

andethnicity,twovariablesthatareoftencorrelated,areparticularlystriking.

Largegeographicaldifferencesexistinallcases,includingincountrieswith

veryhighnationalprevalence(Figure2).

(48) Populationswithalowdemographicweightthathavelittleeffectonnationalprevalence.In

TheGambia,forexample,wherenationalprevalenceis76%,theprevalenceamongcertainethnic

groups(suchastheMandjakandtheWolof,whorepresentlessthan20%ofthetotalpopulation)is

below15%(MICS-Gambia,2012).

Figure 2. Regional variations in the prevalence of FGM

in Mali, Senegal, and Tanzania

Mali (91%*) Senegal (26%*)

Tanzania (15%*)

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Tombouctou

Saint-Louis

Kidal

Gao

Mopti

Sikasso

Koulikoro

Kayes

Matam

Louga

Diourbel

Thies

Kaolak

Fatick

Tambacounda

Kedougou

Sedhiou Kolda

Mara

Arusha

Kilimanjaro

Kagera

Victoria

Shinyanga

Kigoma

Tabora

Rukwa

Mbeya Iringa

Singida Dodoma

Morogoro

Ruvuma Mtwara

Lindi

Pwanu

Tanga

Manyara

80-100%

50-79%

25-49%

10-25%

Below 10%

(*) National prevalence.

Note: There is a more recent DHS for Mali (conducted in 2012-2013), but whose sample did not cover all the

regions of northern Mali (Tombouctou, Kidal and Gao) because of political unrest in 2012 (Mali DHS-V,

2012-2013).

Sources: DHS Mali, 2006; DHS-MICS Senegal, 2010-2011; DHS Republic of Tanzania, 2010.

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Thisisthecase,forexample,inMali,whereFGMisvirtuallynon-existent

inthe(sparselyinhabited)northofthecountry,homenotablytoSonghaiand

Tamasheqpopulations,amongwhomgenitalmutilationisrareornotpracticed

(MaliDHS-IV,2006).InSenegal,levelsarehighestintheeastandthesouth,

inregionsneighbouringMaliandGuinea,where9in10womenaremutilated.

InTanzania,nationalprevalence(15%)isrelativelylow,butthepracticeis

commoninafewregionsinthenortheast(Figure2).

Asmentionedabove(SectionII.3),aswomendonotknowpreciselywhat

formofFGMtheyweresubjectedto,thequestionsinthemostrecentDHSand

MICSsurveysattempttodistinguishjusttwotypesofmutilation:excision

withorwithoutremovaloftissue,andinbulation(Figure3).

Self-reporteddataonthetypeofmutilationareavailableinsurveydata

from22countries.(49)Insixcountries,(50)above5%ofwomenreportednot

knowingwhattypeofmutilationtheyhadundergone,withtheproportion

reaching19%inMauritaniaand26%inMali.

Inmostcountries,theformofmutilationmostoftenreportediscutting

withorwithoutremovaloftissue:in15countries,morethantwothirdsof

womensurveyedreportedthistypeofmutilation(Figure3A).Themost

invasivetypeofmutilation,inbulation,islocalizedineasternAfrica,in

Somalia,Djibouti,andEritrea,where77%,62%and35%ofwomen,respectively,

reportedhavingundergonethistypeofFGM.Itismuchrarerinotherregions,

whereitgenerallyrepresentslessthan10%ofcases(Figure3B).Women’s

responsesinthesesurveysindicatethat,overall,thedistributionoftypesof

FGMpracticedisstableoverthegenerations.(51)Incertaincountrieswhere

themostinvasiveformofFGMispredominant,asinDjibouti,resultssuggest

thatthepracticeofinbulationongirlsisdecreasing.Note,however,thatthis

proportionisnotdenitive,assomegirlsmayundergoitatalaterage(Carillon

andPet it,2009).Finally,severalstudiesshowthatinregionswheremutilation

ismoreoftencarriedoutbyhealthprofessionals,asinNigeriaandKenya,the

leastinvasiveformsseemtobefavoured(Orubuloyeetal.,2001;Njueand

Askew,2004).

Associated factors: education, place of residence,

economic status, and religion

DHSandMICSsurveydatacanbeusedtoexamineandhighlightpossible

relat ionshipsbetweenFGMst atusandanumberofind ividualsociodemographic

variables,suchaslevelofeducation,placeofresidence,economicstatus,and

religion.

(49) In5countries(Iraq,Liberia,Uganda,Sudan,Yemen),thisquestionwasnotincluded.

(50) Eritrea,Mali,Mauritania,Nigeria,Senegal,SierraLeone.

(51) AnexaminationofthedifferenttypesofFGMbygroupofwomensurveyedbasedonacomparison

oftheformsofFGMreportedbytheoldestwomen(45-49years)andthosereportedbytheyoungest

women(15-19years)yieldsthesameresult(UNICEF,2013).

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Figure 3. Geographical distribution of different forms of FGM

in Africa circa 2010

Nigeria

Niger

GhanaTogo

Côte-

d'Ivoire

Liberia

Sierra Leone

Dijbouti

Kenya

Burkina

Faso

Mali

Nigeria

Niger

GhanaTogo

Côte-

d'Ivoire

Liberia

Sierra Leone

Dijbouti

Kenya

Burkina

Faso

Mali

INED

053A16

Cameroon

Central

African Republic

Chad

Benin

Guinea-Bissau

The Gambia

Senegal

Tanzania

Uganda

Eritrea

Ethiopia

Sudan

South

Sudan

Egypt

Mauritania

Guinea

Somalia

Cameroon

Central

African Republic

Chad

Benin

Guinea-Bissau

The Gambia

Senegal

Tanzania

Uganda

Eritrea

Ethiopia

Sudan

South

Sudan

Egypt

Mauritania

Guinea

Somalia

80-100%

50-79%

25-49%

Below 25%

Type unknown

Zero prevalence

30-79%

10-29%

Below 10%

Type unknown

Zero prevalence

A - Percentage of women excised

(a)

B - Percentage of women inﬁbulated

(b)

(%)

(a) With or without removal of tissue (types I and II).

(b) Type III mutilation.

Sources: Most recent DHS and MICS surveys for which data on the type of FGM are available.

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Women’sschoolingisassociatedwithadeclineinFGM(52)inpractically

allcountries(albeittovaryingdegrees):theriskforthemosteducatedwomen

islowerthanthatforwomenw ithnoformaleducation.Insomecount r ies,the

riskofFGMisthreetovetimesgreaterfortheleasteducatedwomenthan

forwomenwithhigherlevelsofeducation,notablyinEgypt,SierraLeone,

Mauritania,andLiberia(Figure4).

Levelofeducationcannotbeinterpretedasadirectlycausalexplanatory

factor,a swomendonotcontrolgenitalcutt ing(a swewillsee,itoccursbefore

schooling),butitcanserveasaproxytomeasuretheinuenceoffamily

backg round.Invest mentinschooling,andnotablygirls’schooling,maycorrelate

withgreateropennesstoargumentsagainstthispracticeandanunderstanding

ofitsnegativeconsequences.Theinuenceofeducationisconrmedbythe

proportionofgirlswithFGMbymother’slevelofeducation:incountrieswith

high,medium,andlowprevalence,theproportionofgirlswhoundergoFGM

decreasesastheirmother’slevelofeducationincreases(UNICEF,2013).

(52) WiththeexceptionofNigeria,whereeducatedwomenmorefrequentlyundergoFGMthan

uned uc ate dwomen .T hisap paren tlyin co nsi stentn din ga r ise sfr omthefactthatonl yt heYorubaa nd 

Igboet hnicg roups pr act ic eF GMinNi ge ria.Theylivein thesout ho ft hecount r y,w hichi sm uc hm or e

urbanizedthanthenorth,andhashigherschoolattendancelevels(AndroandLesclingand,2007).

Figure 4. Relative risk of FGM by level of education

Prevalence > 80%

Prevalence 50-79%

Prevalence 25-49%

INED

054A16

0123456

Relative risk

Somalia

Guinea

Djibouti

Egypt

Mali

Sierra Leone

Eritrea

Burkina Faso

The Gambia

Mauritania

Guinea-Bissau

Liberia

Chad

Côte d'Ivoire

Kenya

Nigeria

Senegal

Country

Note: Relative risk of FGM for women with primary education or less versus women with secondary education

or more, by national prevalence. Relative risk is the ratio of the probabilities of these two groups. A relative risk

of 1 indicates that the risk of FGM is identical in both cases. A value greater than 1 indicates that the least

educated women have a greater risk of FGM than the most educated women.

Sources: Most recent DHS and MICS surveys of countries where national prevalence is above 25%

(Appendix Table A.1).

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Whileeducationseemstobeanimportantfactorintrendsovertime,

surveyresultsalsoindicatethatotherfactors,suchasplaceofresidenceand

economicstatus,alsoplayarole.Theriskofmutilationisalmostalwayshigher

inruralthaninurbanareas(53) (Figure5).

Whilerel ativer i ski sloweroverallforthisfactorthanforlevelofeducation,

thecountrieswheredifferentialsinlevelsofeducationarehighest(54)arealso

thosewherewomeninruralareasaremostdisproportionatelyatriskof

mutilation(Figure5).

(55)

Note,however,thatwomen’spl aceofresidenceatthe

timeofthesurveyisnotatrulyaccurateindicatorofwomen’sgeographical

origin.Becauselevelsofrural-urbanmigrationinAfricaarehigh(Teminet

al.,2013),

(56)

anon-negligibleproportionofwomenwhowerelivinginanurban

areaatthetimeofthesurveyswereoriginallyfromruralareas.Inspiteofthis

limitation,whichisinherenttothisvariable,itisalsopossiblethatthegreater

ethnicandsocialdiversityfoundincities,andthustheopportunitytohave

(53) WiththeexceptionofNigeria(cf.prev iousnote).

(54) Egypt,SierraLeone,Mauritania,andLiberia.

(55) Thisdoubtlessreectsafairlystrongcorrelationinthesecountriesbetweenlevelofeducation

andrural/urbanstatus.

(56) Notablyduringadolescence(Teminetal.,2013)andthusduringperiodsfollowingthetime

whentheriskofmutilationishighest,i.e.beforetheageof10years(SectionIII.2).

Figure5. Relative risks of FGM in Africa by place of residence

Prevalence > 80%

Prevalence 50-79%

Prevalence 25-49%

INED

055A16

Relative risk

Country

01234

Somalia

Guinea

Djibouti

Egypt

Mali

Sierra Leone

Eritrea

Sudan

Burkina Faso

The Gambia

Mauritania

Guinea-Bissau

Liberia

Chad

Côte d'Ivoire

Kenya

Nigeria

Senegal

Note: Relative risk of FGM among women residing in rural versus urban areas, by national prevalence.

Relative risk is the ratio of the probabilities for women in these two groups of being (rather than not being)

mutilated. A relative risk of 1 indicates that the risk of FGM is identical in both cases. A value greater than

1indicates that women in rural areas have a greater risk of mutilation than women in urban areas.

Sources: Most recent DHS and MICS surveys of countries where national prevalence is above 25%

(Appendix Table A.1).

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contactwithcommunitiesthatdonotpracticeFGM,mayaffectindividual

expectationsandpracticesovertime.Thishypothesisissupportedbydata

fromcertaincountriesontherelationshipbetweenwomenrespondents’place

ofresidenceandtheirdaughters’riskofmutilation:(57)InKenya,forexample,

thedaughtersofwomensurveyedinruralareasarefourtimesmorelikelyto

haveundergoneFGMthanthoseofwomenlivinginurbanareas.InBurkina

Faso,Mauritania,andSenegal,therelativeriskis2,whileelsewhereitisclose

to1(UNICEF,2013).

DataonsocioeconomicstatusandFGM(Figure6)showthattheriskis

mostoftenhigherinverypoorhouseholdsthaninrichhouseholds,exceptin

thecasesofNigeria,Mali,andtheGambia,whereinequalityislowandregional

(andethnic)differencesaregreater.Incontrast,relativeriskisparticularly

highinMauritania,Guinea,andEgypt.

Whilewealthislinkedtoothersocialcharacteristics(inparticular,place

ofresidenceand/orhouseholdlevelofeducation),itremainsclearlyassociated

withdecreasedriskofFGMincertaincountries.

(57) Girls’placeofresidenceismorestablethanthatoftheirmothers,althoughmobilityinchildhood

isrelativelywidespreadinAfrica,notablyforyounggirls,duetofostering.

Figure6. Relative risk of FGM by household economic status

Prevalence > 80%

Prevalence 50-79%

Prevalence 25-49%

INED

056A16

Relative risk

Country

Somalia

Guinea

Egypt

Sierra Leone

Eritrea

Sudan

Burkina Faso

The Gambia

Mauritania

Guinea-Bissau

Liberia

Chad

Côte d'Ivoire

Kenya

Nigeria

Senegal

Mali

0123456789101112131415161

718

Note: Relative risk of FGM among women living in the poorest households (lowest quintile) versus women

living in the richest households (highest quintile). Relative risk is the ratio of the probabilities for the women in

these two groups of having undergone FGM. A relative risk of 1 indicates that the risk of FGM is identical in

both cases. A value greater than 1 indicates that poorer women have a greater risk of mutilation than

wealthier women.

Sources: Most recent DHS and MICS surveys in countries where national prevalence is above 25%

(Appendix Table A.1).

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Regardingreligion,datafromtheDHSandMICSsurveysshowthat

FGMoccursamongpopulationsthatdescribethemselvesasanimistaswell

asinpopulat ion sofadherentstot het hreegreatmonotheisticfait hs,Islam,

ChristianityandJudaism(UNICEF,2013).Becausepopulationsthatdescribe

themselvesasMuslimmakeupamajorityofthepopulationinmostcountries

whereFGMoccurs,thepracticehaslongbeenthoughtofaslinkedtoIslam

(Boddy,1991).In2007,Al-AzharUniversitypublishedareligiousedict

(fatwa)condemningFGMandrecallingthatthepracticeisnotmentioned

intheKoran.Thispositionwasechoedbymanyreligiousleadersatthe

nationalandlocallevelsinanumberofcountries(UNFPAandUNICEF,

2009).Nevertheless,incertaincountries(Eritrea,Guinea,Egypt,Mali,

Mauritania,SierraLeone,andChad),largeproportionsofbothmenand

women

(58)

considerthepr act icetobeareligiousobl igation(UNICEF,2013).

Severalrecentstudie shaveshownthatt herelationsh ipbetweenIslamand

thepracticeofFGMisnotsystematic,andvariesgreatlywithcontext.

Theseethnographicstudiesshowthatreligiousbeliefscoexistwithother

socialnormsonFGM(Boddy,1991;Johnson,2001).Astudycarriedoutin

BurkinaFaso(HayfordandTrinitapoli,2011),acountrywithanimist(10%),

Musl im(60%),andChristian(30%)populations,

(59)

showedthattheimpact

ofrelig iononthispract ice(bothatindiv idualandcollectivelevels)differs

bylevelofprevalence:incommunitieswhereprevalenceishigh,Muslim

religiousafliationisnotcorrelatedwiththepracticeofFGM,whilethe

oppositeistrueinthosewithlowprevalence.Theauthorsexplainedthis

intermsofthedominanceofgroupsocial normsinthe firstcase,

independentlyofreligiousafliation,arguingthatinthesecondcase,

religiousbeliefsarethedominantinuence.Ultimately,thelinksbetween

religionandFGMarecomplexandmultiform,andethnographicapproaches

areneededtoar riveatamorepreciseunderstand ingofthem(Boyle,2005;

Johnsdotter,2007;Johnson,2007).

The conditions in which FGM is practiced

FGMhaslongbeendescribedintheanthropologicalliteratureinthe

contextofritesofpassage,notablyforthetransitiontoadulthood(SectionI.1).

FindingsfromtheDHSandMICSsurveysontheconditionsinwhichthis

practiceiscarriedout(60)revealthatitisnowmostoftendisconnectedfrom

thisritualdimension.Inallcountries,virtuallyallofthewomensurveyed

(58) Between30%and60%.Inthesecountries,morewomenthanmenconsiderFGMtobea

religiouslyrequiredpractice,withtheexceptionofMauritaniaandEgyptwherethereverseistrue

(UNICEF,2013).

(59) InBurkinaFaso,thecorrelationbetweenethnicgroupandspecicreligiousafliationisquite

low.ReligiousdiversityisfoundinmostethnicgroupsinBurkinaFaso,apartfromthenomadic,

majority-MuslimPeulandTouaregpeoples(HayfordandTrinitapoli,2011).

(60) Thecollecteddataareaffectedbyrecallbiases,aswomen(andparticularlytheoldestwomen)

areoftenreportingdistantevents.Additionally,somewomenwhounderwentFGMataveryyoung

agedonotclearlyrememberthecircumstancesoftheevent.

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reportedhavingundergoneFGMbeforetheageof15;in18outof22countries

wheredataonageatFGMareavailable,themajorityofwomenweremutilated

beforeage10(Figure7).

InEgyptandtheCentralAfricanRepublic,morethanhalfofwomen(58%

and60%,respectively)underwentFGMbetweentheagesof10and14years.

Inonlytwocountries–SierraLeoneandKenya–werearelativelysubstantial

proportionmutilatedatlaterages,with23%and29%,respectively,undergoing

FGMafterage15(Figure7).Inmostcountries,ageatmutilationalsovaries

byethnicity.ThisisthecaseforexampleofKenya,(61)wheremeanageatFGM

amongwomenaged15-49rangedfrom9yearsamongtheSomalito16years

amongtheKambaandKalenjin(UNICEF,2013).

WhileFGMcontinuestobeassociatedwithcollectiveinitiationrites

incertainethnicgroups,inKenyaandChadforexample(Ahmadu,2001;

(61) Accordingtotheresultsofthe2008-2009DHS.

Figure 7. Percentage of women aged 15-49 years reporting having undergone

FGM before age 15 or age 10, by national prevalence

Prevalence > 80% Prevalence 50-79% Prevalence 25-49%

Prevalence 25% of which before age 10

INED

057A16

Country

Cameroon

Iraq

Niger

Togo

Tanzania

Guinea

Yemen

Egypt

Mali

Sierra Leone

Eritrea

Benin

Burkina Faso

The Gambia

Mauritania

Guinea-Bissau

Chad

Central African Republi

Côte d'Ivoire

Kenya

Nigeria

Senegal

0 10 20 30 40 50 60 70 80 90

100

Percentage

Sources: Most recent DHS and MICS surveys from the 22 countries for which data on age at FGM

are available.

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Droz,2000;Leonard,1996),inotherregions,suchastheGambia,thisis

nolongerthecase:intheseregions,FGMispracticedindividuallyrather

thaninagroup,isdisconnectedfromanygroupcelebrations,andmay

progressivelyloseitssocialsignication(Hernlund,2001).Moreover,in

halfofthecountrieswheremothers’reportsontheirdaughters’ageatFGM

areavailable,(62)themajoritywerecutbeforeage5,suggestingthatageat

FGMmaybedecre asing(UNICEF,2013).Thesendingsmustbeinterpreted

withcaution,however:thiseffectcouldbeatleastpartlyduetothefact

thatcertai ngirlswhohadnotyetundergoneFGMatthetimeofthesur vey

willundergoitatalaterage.

Inallofthecountriessurveyed,mutilationismainlyperformedby

“traditional”practitioners(womencircumcisersorexciseuses,villagematrons).

Thereareexceptions,however,asinEgypt(63)andSudan,whereathirdof

womenreporthavingbeencutbyahealthprofessional:physiciansinEgypt,

andnursesormidwivesinSudan(UNICEF,2013).InEgypt,theproportion

ofgirlscutbyahealthprofessionalhasconsiderablyincreasedovertime,

from55%in1995to77%in2008.Thistrendtowardsmedicalization(64)of

thepracticehasalsooccurredinKenya,wherearound40%ofprocedures

wereperformedbyhealthprofessionalsinthelate2000s,versusathirdin

thelate1990s(Shell-Duncanetal.,2001;UNICEF,2013).Thisrecenttrend,

whichinsomecaseshasaccompaniedadeclineinthepractice,asinKenya

(SectionIV.2),seemstobeexplainedbyacounter-productiveeffectofthe

rstcampaignsagainstmutilationinthe1990s(SectionVI.1).Theseearly

campaignsfocusedonthehealthrisksofFGM,notablyshort-termriskssuch

ashaemorrhageandinfections,suggestingthattheywouldbedecreasedif

mutilationwasperformedbyhealthprofessionalsandundermorehygienic

conditions(Shell-Duncan,2001).

IV. The social dynamics of abandonment

or perpetuation of FGM

TheghtagainstFGMhasbeenshapedbythedebatethatsurroundsthis

practice,whichinten siedinthe1990sundert heimpetusofmajorinter national

organizations(ToubiaandSharief,2003;Boyle,2005).Thersttospeakout

werefeministresearchersinbothNorthandSouth,whogenerallysawthe

practiceasamanifestationofwomen’soppressioninapatriarchalsystem.But

(62) NamelyNigeria,Mali,Eritrea,Ghana,Mauritania,Senegal,Ethiopia,Niger,BurkinaFaso,and

Côted’Ivoire(UNICEF,2013).

(63) In1994,theEgyptianMinistryofHealthissuedadecreestrictlyregulatingthepracticeofFGM,

authorizingitonlyinalimitedsetofpublichospitals.Thisdecreewasrepealedunderpressurefrom

women’sright sorganizations(whosawitasalegitimizationofthepractice).In1997anewdecree

wasissuedprohibitingthepracticethroughoutthehealthcaresystem.

(64) DenedasthetendencytocallonahealthprofessionaltoperformFGMratherthanatraditional

practitioner(SectionVI.1).

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thisperspective,partlyinstrumentalizedbyNorthernhegemonicdiscourse,

wasstronglycriticized,notablyinpostcolonialstudies,

(65)

wherecertainfeminist

approache swerecondem nedas“imperialist”,“neo-colonial”,andeven“raci st”

(Wade, 2012).

(66)

Thiscontrastinapproachesharksbacktoanolderdebate

betweenrelativismanduniversalism,hereinthecontextofaglobalized,

transnationalworld,wherequestionsofsexandracearestronglyintertwined

incount r iesofi mmigr ation(Dorlin,2009;HernlundandShell-Duncan,2007,

Watson,2005).

1. The dynamics of social change

Independentlyofparticularconditionsandjustications,individuals

experienceFGMasaruleornormthatisinteriorizedbyeveryoneinthe

group,withtransgressionleadingtosocialsanctions:uncutwomenare

seenas“dirty”or“obscene”.Butbeyondimpurity,whatisatstakeisnon-

recognit ionasawoman,andthusasafuturewifeandmother,asdesignated

forexamplebythetermbilakoro(67)amongtheMalinkeofMali.Different

theoreticalapproachestotheabandonment(orperpetuation)ofFGM,in

bothitscountriesoforiginandinthecontextofmigration,havethus

focusedonitsstatusasasocialnorm.

Afirstapproach,inspiredbymodernizationtheory,considersthe

determinantsofthepracticeasdocumentedinsociodemographicsurveys.

Itsproponentsarguethatmacro-socialfactorssuchaseconomicdevelopment,

urbanization, increasesin schoolenrolment, andpaid employment

–accompaniedbyaweakeningoftheroleoffamiliesandaprivatizationand

indiv idualizationofbehaviour–willleadtoadeclinein“traditional”practices

suchasFGM(Boyleetal.,2002;Far inaandOr tensi,2014a).Otherapproaches

focusonfactorslinkedtogenderinequality,arguingthatthepracticewill

onlydecreasewhenwomenachievegreaterautonomyandindependence,

andhencemoreroomformanoeuvreindecision-makinginthemaritaland

familyspheres(Yount,2002).Themostrecentapproacheshaveprovidedt he

fr ameworkfortheprogrammesofinternationalorganizationsinrecentyears

(Lewnesetal.,2005;UNFPAandUNICEF,2014;UNICEFandInnocenti

ResearchCentre,2010).TheystilltreatFGMasaquestionofgenderinequality,

butarguethatthepracticecanonlybeabandonedindividuallywhenthere

isacriticalmassofuncutwomenwithinagivengroup.Applyingthet heory

(65) Postcolonialapproaches,generallytracedbacktoEdwardSaïdandhisbookOrientalism,

publishedin1978,aimtohighlighthowWestern,imperialistdiscourse,baseduponacolonial

histor y,“hasconstructedandcontinuestoconstructavisionofthecolonizedorracializedOther”

(Benellietal.,2006).

(66) AccordingtoWade,beginninginthe1990s,postcolonialstudieschallengedtheManichean

perceptionofFGMasasymptomofculturalinferiority.Fromtheirpointofview,Westernfeminist

engagementagainstFGMispartofan“imperialist”project.

(67) InMalinkeculture,apejorativetermforan“uncircumcized”or“uncut”person(BellasCabane,

20 08).

A. Andro, M. LescLingAnd

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ofsocialconventions(6 8)tothepracticeofFGM,MackieandLeJeune(2009)

proposeananalyticalframeworkthatconsiderstheeffectsofsocial,moral,

andlegalnorms.Fortheseauthors,eveninacontextofmoralsanctions

(guiltaboutsubjectingone’sdaughterstoviolence)andlegalsanctions(fear

ofnesorimprisonment),sanctionsfornon-compliancewithsocialnorms

mayprovestronger,sinceinadditiontothesocialstigmaofnon-conformity,

theyoftenresultinexclusionfromthemarriagemarket(Lewnesetal.,2005;

Mackie,1996;MackieandLeJeune,2009).(69)Underthisview,thepractice

canon lybeabandonedwhen,follow ingacollectivediscussion(andapublic

declaration),a“criticalmass”ofmenandwomendecidetogiveitup,and

areabletoconvincealargeportionofthecommunitythatdoingsois

necessary.NGOprogrammessupportedbyinternationalorganizationsin

thecountrieswhereFGMispracticedhavepursuedthisapproach,whichis

centredondialoguewiththecommunity.Thesecampaigns,oftenlocalin

sc ale,haveh adcontrast ingeffectsindif ferentcontexts(UNICEFandInnocenti

ResearchCentre,2010),andmethodologicallimitationsmakeitdifcultto

assesstheirefcacy(Askew,2005).Moregenerally,whileavailabledata,

notablyfromDHSandMICSsurveys,canbeusedtotracktrendsinthis

phenomenon,theymustbeinter pretedwit hcautionont heexplan atorylevel.

2. The effect of anti-FGM policies

What is being measured?

Arstapproachtomeasuringtrendsinthepracticeisobviouslytotrack

howitchangesovertime.However,asrespondentstotheDHSandMICS

surveysaremainlywomenaged15-49,andtheprocedureinmostcountries

iscarriedoutatearlyages(below15years),theimpactofthecampaignsof

thelasttwodecadesisnotimmediatelyvisible.Amongthe30countrieswhere

surveyshavebeenperformed,datacoveringaperiodofmorethan15years

areavailableforonlyve:Côted’Ivoire,Egypt,Mali,theCentralAfrican

Republic,andSudan(AppendixTableA.1).Inadditiontothelimitations

inherenttocomparingtheresultsofcross-sectionalsurveysperformedat

differenttimesondifferentsamples,

(70)

themai nbi asispossibleunder-estim ation

ofthephenomenon,giventhatthedataaredrawnentirelyfromwomen’sself-

reports.Inthecontextofincreasingpenalization(SectionI.2),apparentdeclines

(68) Thetheoryofsocialconventionslooksathowindividualsbehaveinthefaceofuncertainty.In

thecaseofFGM,familieshavetheirdaughterscutinordertoadapttheirbehaviourtothedominant

socialnorm.Conversely,ifacertainnumberoffamiliesdecidenottohavetheirdaughterscut,their

individualbehavioursmayleadtochangeinthesocialconventionornorm.

(69) TheconnectionbetweenthepracticeofFGMandaccesstothemarriagemarketisattheheart

ofMackieandLeJeune’smodel.Mackie(1996)drewaparallelbetweenthecessationoftheancient

practiceoffootbinding(itselftiedtomarriage)intheearlytwentiethcenturyinChinaandthe

possiblefuturepatternofabandonmentofFGM.

(70) TheselimitationsarenotspecicallyconnectedtothemeasurementofFGM,butrelatetopossible

changesinsamplingbetweensurveys:inclusion/exclusionofcertainregions,selectioncriteriafor

respondents(marriedwomenorallwomen,etc.).

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inthepracticemaysimplyreectunder-reporting,andnotanactualdecrease.

InBurkinaFaso,forexample,theprevalencefoundinthe2010surveywas

4percentagepointshigherthanin1998-1999(72%).Therstlawmaking

FGMacriminaloffensewasadoptedin1996,andt herewerearoundahundred

convictionsbetween1997and2005.TheoutlawingofFGMseemstohaveled

tounder-reportingofthepracticebywomenrespondentsinthe1998-1999

survey(Diopetal.,2008).

Forcountrieswheresurveydataaremorerecent,itisstillpossibletocarry

outagenerationalanalysisbycomparingobservedprevalenceintheyoungest

andoldestagegroups,orbycomparingobservedprevalenceamongwomen

respondents(mothers)andtheirdaughters.However,notonlyisreported

prevalenceingirlsliabletobeaffectedbymothersunder-reportingoftheir

daughters’andtheirownmutilation(forfearofprosecution);butitisalsoa

poornalmeasureofprevalence.DependingontheageatwhichFGMis

practiced,someofthedaughtersofsurveyedwomen(aged0-14years)have

notyetbeencutatthetimeofthesurvey,butarestillatrisk.

Finally,questionsintroducedmorerecentlyintotheDHSandMICSsur veys

offerinformationonwomen’sandmen’sattitudestoFGM,uncoveringpossible

ongoingorfuturechanges.

Mixed trends, with contrasts between countries

AsthelegalframeworkonFGMisveryrecentinmostcountries(SectionI.2),

itisdifculttodrawanyconclusionsontheimpactofnewlawsonchanges

inthepracticeovertime.Whilelegislationseemsnecessary,itisnotsufcient,

andprogrammestocombatFGMalsoincludeawarenesscampaigns(Rahman

etal.,2000;Shell-Duncanetal.,2013).Theseprogrammesoftentargetlocal

populationsatarelativelysmallscale:insomecontexts,atthelocallevel,

decreaseshavebeenobservedfollowingtheimplementationofprogrammes

basedonwinningoverthecommunity(shiftingthenorm).TherstNGOto

implementthetheoreticalframeworkdevelopedbyGerryMackieinits

programmestocombatFGMistheassociationTostan

(71)

whichhasbeen

workinginSenegal since1991,and whose “communityempowerment

programme”hasbeendeployedsince2007inanumberofotherAfrican

countries.ActionscarriedoutinSenegalesevillagessincethelate1990shave

yieldedpositiveresults,accordingtonumerouseldevaluations(UNICEFand

InnocentiResearchCentre,2010).However,onabroaderscale,trendsare

uncertain.

Inthe11countrie swheremultiplesur veyshavebeenc arriedout,thetot al

periodcoveredismoreth an10years.Thegeneralt rendina llofthe secountries(72)

isadecreaseinthepractice,butthepaceofchangediffersbetweencountries

(Figure8).Insevencases,decreasesweresm all( lessthan5percentagepoints).

(71) http://fr.tostan.org/

(72) WiththeexceptionofBurkinaFaso(SectionIV.2).

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Thisisnotablythecaseincountrieswherethepracticeisnearlyuniversal:in

Egypt,overthecourseof19years(1995-2014),prevalencefellfrom97%to

92%;inMali,in17years(1995-2012),itfellfrom94%to89%.Incontrast,

relativelylargedeclineswereobservedintheCentralAfricanRepublicand

Kenya.IntheCentralAfricanRepublic,theproportionofwomenaged15-49

withFGMdroppedfrom43%in1994to36%in2000,26%in2006,and24%

in2010.InKenya,theproportionfellfrom38%in1998to27%tenyearslater

(Figure8).

Thesetrendsareconrmedbycomparingprevalenceindifferentcohorts

ofwomen:inallcountries,thereisageneraldownwardtrendoverthegenerations

(Figure9).Inthecountrieswherethepracticeisnearlyuniversal,however,

differencesremainrelativelysmall,withtheexceptionofSierraLeoneand

Egypt,wheretheprevalencelevelsobservedintheyoungestgroups(15-19

and20-24years)arearound10percentagepointslowerthanthoseinolder

groups.Amongcountrieswhereprevalenceisbetween50%and79%,Burkina

FasoandLiberiastandout,showingrelativelylineardeclinewithdecreasing

age,asignofgenuinechangeinthepracticeovertime.Finally,amongcountries

whereFGMisaminoritypractice,thecountriesthathaveshownthemost

progressoverthegenerationsareKenya,theCentralAfricanRepublic,and

Nigeria(Figure9).

Anotherwaytocapturethesocialdynamicsoftheabandonmentofthis

practiceistoexaminetheopinionsofwomen(andmen)whoexpresssupport

foritscontinuation.QuestionsaddedtotheFGMmodulesoftheDHSand

MICSsurveysprovideameanstoassessoverallsupportforFGMamongstall

respondentswhoreported,independentlyoftheirownFGMstatus,being

awareofthepractice(Figure10).

Inallcountries,womenwithFGMarefarmorelikelytofavourthe

continuationofthepracticethanothers:differencesbyFGMstatusareoften

considerable,notablyinMaliandtheGambia,wheremorethan8in10women

withFGMfavourthecontinuationofFGM,versusaverylowproportion(7%

and3%respectively)ofnon-FGMwomen.Int wocountries,GuineaandSierra

Leone,theopinionsofFGMandnon-FGMwomendivergelessmarkedly(70%

versus49%inGuinea,69%versus25%inSierraLeone),doubtlessreecting

greatertolerancefortraditionalpracticesamongnon-FGMwomen.Andnally,

incount r ieswhereinter medi atenat ion alprevalencereect sdist inctpopulations

withwidelyvar y ingprevalence,opinionsal sodi fferwidely,withFGMwomen

muchmorelikelytosupportthepracticethantheaverage(Figure10).These

resultsreectthecurrentopinionofadultwomen,alargemajorityofwhom

arenolongerintheagegroupatriskofmutilation.Amongwomenwhohad

undergoneFGM,thequestionwasaskedwellaftertheactualprocedure–that

thewomenthemselveshadnotchosentoundergo.

Anotherwaytoaddressthequestionistolookatchangesinopinionover

time(Figure11).Overall,theproportionofwomenwhofavourcontinuation

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Figure 8. Changes in the proportion of women with FGM aged 15-49 by

national prevalence in 11 African countries

1995

2000

2003

2005

2008

2014

1995

2001

2006

2010

2012

1990

2000

2014

1999

2005

2012

1998

2003

2006

2010

2000

2007

2011

1994

2000

2006

2010

2000

2004

2010

1994

1998

2005

2006

2011

1998

2003

2008

1999

2003

2007

2008

2011

2013

Prevalence > 80%

Prevalence 50-79%

Prevalence 25-49%

INED

058A16

Guinea

Egypt

Mali

Burkina Faso

Sudan

Mauritania

Chad

Central African

Republic

Côte d'Ivoire

Kenya

Nigeria

Percentage of women aged 15-19 with self-reported FGM

Survey yearCountry

0 10 20 30 40 50 60 70 80 90 100

Sources: DHS and MICS data from the 11 countries where surveys have been performed in different years,

covering a total period of at least 10 years (Appendix Table A.1).

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Figure 9. Percentage of women with FGM in each age group,

by national prevalence

Countries where prevalence is above 80%

Countries where prevalence is between 50% and 79%

Countries where prevalence is between 25% and 49%

Somalia Guinea Djibouti Egypt Mali Sierra Leone Eritrea Sudan

Burkina Faso The Gambia Mauritania Guinea-Bissau Liberia

Chad Côte d'Ivoire Kenya Nigeria Senegal Central African

Republic

Percentage

100

Country

Percentage

100

Country

Percentage

100

Country

Age 45-49

Age 40-44

Age 35-39

Age 30-34

Age 25-29

Age 20-24

Age 15-19

INED

059A16

Sources: Most recent DHS and MICS surveys in countries where national prevalence is above 25% (Appendix Table A.1).

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ofthepracticehasbeendecreasing,includingincountrieswherethepractice

isnearlyuniversal,asinEgypt,wherethelevelofsupportfellfrom82%to

62%in13years,andinSierraLeone,whereitfellfrom86%to66%inless

than5years(SierraLeone)(Figure11).

Theseresultspartlyconrmchangesintheprevalenceofthepractice

overthegenerations(Figure9).Inthecountries(7 3)whereresultsonthis

quest ionarealsoavailableformenonseveraldates(datanotshown),changes

(73) Benin(2001,2006);BurkinaFaso(1998-1999,2003,2010);Guinea(1999,2005);Mali(2001,

2006,2010);Niger(1988,2006)(UNICEF,2013).

Figure 10. Proportion (%) of women aged 15-49years who reported

supporting the continued practice of FGM, by respondent’s FGM status

Prevalence > 80%

Prevalence 50-79%

Prevalence 25-49%

Prevalence < 25%

Women without FGM

Women with FGM

INED

060A16

Somalia

Guinea

Djibouti

Mali

Egypt

Sierra Leone

Eritrea

Sudan

Burkina Faso

The Gambia

Ethiopia

Mauritania

Guinea-Bissau

Chad

Côte d'Ivoire

Kenya

Senegal

Nigeria

Central African Republic

Yemen

Tanzania

Benin

Iraq

Togo

Ghana

Niger

Cameroon

Uganda

Country

020406080

100

Percentage

Sources: Most recent DHS and MICS surveys.

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Figure 11. Change in percentage of women aged 15-49 years

who reported supporting the continuation of FGM

Prevalence > 80%

Prevalence 50-79%

Prevalence 25-49%

Egypt

Eritrea

Guinea

Mali

Sierra Leone

Burkina Faso

Ethiopia

The Gambia

Mauritania

Chad

Côte d'Ivoire

Guinea-Bissau

Kenya

Senegal

Country Year

1995

2000

2003

2005

2008

1995

2002

1999

2005

2001

2006

2010

2005

2008

1998-1999

2003

2006

2010

2000

2005

2005-2006

2010

2000-2001

2007

2011

2004

2010

1998-1999

2006

2010

1998

2008-2009

2005

2010-2011

0 10 20 30 40 50 60 70 80 90

100

Percentage

INED

061A16

Sources: DHS surveys in countries where prevalence is above 25% and where opinions on the abandonment or

continuation of FGM have been recorded on several occasions.

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ofopinionamongmenovertimearefairlysimilartothoseamongwomen.

Forexample,inGuineaandMalibothwomen’sandmen’sopinionshave

changedlittle,assupportforthepracticehasremainedhigh.Thisreects

thepersistenceofstrongsocialnormsinfavourofFGMinthesesocieties

(UNICEF,2013).

Differencesbetweenprevalenceandpercentageofopinioninfavourofthe

continuationofthepracticedonotcompletelypredictfuturechanges.In

contextswhereFGMisnowcondemned,itismoredifculttoexpresssupport

forthepractice.Tobetteraccountfordifferencesbetweenintentionsandactual

behaviours,the“stagesofchange”model,originallydevelopedinhealth

psychologytocapturechangesinbehaviourovertime,hasbeenappliedto

FGM(Shell-DuncanandHernlund,2006).

(74)

Startingfromthehypothesis

thataperson’sactualordesiredbehaviourisinuencedbyothers,theauthors

identiedvecategoriesofreadinessforchangeinthepracticeofFGM,

comparingtheopinionsofwomen(withorwithoutFGM)onthecontinuation

orabandonmentofthepracticeandtheirintentionsfortheirdaughters.Women

whoreportedthattheysupportedthepracticeandthattheyhadhadtheir

daughterscutorintendedtodosowereclassiedas“willingadherents”;at

theoppositeextreme,womenwhosupportedabandonmentofthepracticeand

whosaidtheywouldnothavetheirdaughterscutwereconsidered“willing

abandoners”(AppendixtableA.3).Applyingthismodelinaqualitativestudy

inthreeregionsintheGambiaandSenegal,Shell-DuncanandHernlund(2006)

showedthatthiscategorizationcanshedlightontrendsinFGM,whichisnot

amatterofpurelyindividualdecision-making.ThemostrecentUNICEFreport

presentsthedistributionofwomenacrossthesevecategoriesforanumber

ofcountries(Figure12).

Unsurprisingly,theproportionofwomenidentiedas“willingadherents”

ishighestincountrieswhereprevalenceisabove80%,andconversely,in

countrie swithlowprevalence,themajorityofwomenare“willi ngabandoners”.

Thisindicatorisconsistentwithchangesinprevalenceandopinionsovertime:

incount r ieswhereprevalenceishigh,whensupportforabandonmentincreases,

prevalencedecreasesamongtheyoungestwomen(Figures9and11),with

increasingnumbersofwomenclassiedas“willingabandoners”or“reluctant

abandoners”(Figure12).Thisistrue,forexample,ofEgyptandSierraLeone,

whereasinGuineaandMalilittlechangehasbeenobserved.(75)Similarly,in

KenyawherebothFGMandsupportforitscontinuationhavesubstantially

declinedover10years(Figures9and11),nearly6in10women(Figure12)

arenowwillingabandoners.

(74) Thismodel,initiallydevelopedinthecontextofsupportfortobaccocessation,wasthenapplied

toaddictivebehavioursinotherareas(drugaddiction,diet,promotionofphysicalexercise,risky

sexualbehaviour)(Prochaskaetal.,1994).

(75) InEgyptandSierraLeone,thetwocategoriesofwomenwhofavourabandonmentofthe

practice(willingandreluctant)makeup25%and9%ofallwomen,versus4%inMaliandGuinea

(Fi gure12).

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Thiscategorizationcouldberened,forexample,withdataonspouses’

opinions,butitneverthelessprovidesarelativelyclearimageofthedynamics

ofongoingchange.Theanalysisshouldbeextendedtoallcountrieswhere

dataonthesevariablesisavailablefromdifferentsurveys,withaviewto

measuringapossiblecontinuuminthesestagesofchange.

3. The effect of migration

ThequestionoftheabandonmentofFGMisalsoposedincountriesof

im migration,butunderver ydifferentconditions.Inthesesocieties,thepractice

hasnohistoricalfoundationsandi sst ronglycondemnedbythelaw.Itisw idely

seenasviolationoftherightsofchildren,andisafactorinthestigmatization

offamiliesfrom“visibleminorities”whoareconsideredatriskofengagingin

thepractice.InEurope,thisquestionhasbeenexaminedinqualitativestudies

carriedoutinthe2000s(Behrendt,2011;BergandDenison,2013;Dieleman,

2010;Johnsdotter,2007;Johnsdotteretal.,2009;Johnson,2007),andmore

recentlyintwoquantitativesurveysperformedinItaly(2010)andFrance

(2007-2009).

Figure 12. Distribution of women aged 15-49 years among the ﬁve categories

of readiness to change FGM practice, in 9 countries

INED

062A16

Willing adherent

Reluctant adherent

Contemplative

Reluctant abandoner

Willing abandonner

Country

Tanzania

Nigeria

Kenya

Mauritania

Sudan

Sierra Leone

Egypt

Mali

Guinea

Percentage

0102030405060708090 100

Prevalence > 80%

Prevalence 50-79%

Prevalence 25-49%

Prevalence <25%

Sources: Most recent DHS-MICS surveys from a selection of countries (UNICEF, 2013).

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Thersteffectdirectlylinkedtomigration–theselectioneffect–was

showninboththeFrenchandItaliansurveys,notablyintermsoflevelof

educationandgeographicorigin(AndroandLesclingand,2008;Farinaand

Ortensi,2014b).Anothereffectisexpectedinthelongerterm,namelya

decreaseinthepracticeamongthechildrenofimmigrants,underthe

as sumptionthatt heinuenceofotherreferencegroupswillover r idethatof

origincountrycommunities,leadingtoprogressivechangeinnormsand

behaviours(Farina andOrtensi, 2014b).Someresearchershavealso

hypothesizedacorrelationbetweenpoverty,discrimination,andthe

continuationoftraditionalpracticesfromthecountryoforigin(Barth,1969).

Underthishypothesis,FGMinFranceshoulddeclineasthesocialstatusof

therelevantgroupsincreases.Similarly,thepracticeofFGMmaydecrease

infamilieswhichusetheresourcesofthehostcountry(education,salaried

employment,etc.)toimprovetheirsocialandfamilystatus;incontrast,it

maypersistinfamilieswheretheconditionsofmigrationreinforcegender

inequalities,regardlessofsocialstatus.Nevertheless,minorities’experiences

ofdiscriminationandtheirdisadvantagedpositionsinsocietymaygiverise

to“reactiveculturalism”,wherebytraditionsallowingthemtoafrmtheir

identityasmembersofthegrouparerekindled(Coene,2007).Generally

speaking,migrantpopulationsareconfrontedwithtwocompetingsystems

ofrepresentations:incountriesofimmigration,FGMisseenasagrave

violationofhumanrights,whi leinthecountriesoforiginwherethepractice

iswidespread,itisasocialnorm.Migrantsmustthusreconciletwo

contradictorypressures.Thiscanleadtoparentalstrategiessuchashaving

onlyoneoftheirdaughterscut,mostoftentheeldest(AndroandLesclingand,

20 08).

Finally,asmentionedabove(SectionI.2),inadditiontothesocialstigma

associatedwithFGM,thepracticeisillegal,andpractitionerscanbeprosecuted

inthecount r yofimmigrat ioneveniftheprocedurewasperformedel sewhere

(principleofextrater r itoriality).Thislikelymakeswomenallthemorereticent

toreportthatofanyoftheirdaughter(s)haveundergoneFGM.IntheFrench

andItaliansurveys,tolimitthisbias,theprevalenceofthepracticeamong

thedaughtersofimmigrantswasmeasuredboththroughthemother’sreports

ontheirdaughters’FGMstatusandthroughresponsestoquestionsonthe

mother’sand/orthefather’sintentions.(76)TheriskofFGMwascon siderably

lowerfordaughtersborninFranceorItalythanforthosebornabroad,

conrmingthedirecteffectofmigrationonthispractice.

(77)

Moreover,all

otherthingsbeingequal,theriskofmutilationislowerintheyoungest

(76) TheItaliansurveyonlyfeaturedonequestiononmothers’intentionswithregardtothepossible

cuttingoftheirdaughters.IntheFrenchsurvey,furtherquestionswereaddedontheintentionsof

thefatherandofthefamilyresidinginthecountryoforigin.

(77) InFrance,allotherthingsbeingequal(daughter’sageandmother’syearofbirth,levelof

education,andcountr yofchildhoodsocialization),adaughterborninFranceisthreetimesless

likelytoundergoFGMthanonebornabroad(AndroandLesclingand,2008).

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cohorts,doubtlessreectingeffectsofanti-FGMcampaignsandcriminal

prosecutionsinbothcountriesofimmigration

(78)

andcountriesoforigin

(AndroandLesclingand,20 08;Far inaandOrten si,2014b).Finally,analysis

ofdataontheintentionsofparentsandoffamilymembersinthecountry

oforiginsuggeststhatlevelsofriskamongdaughterswhohadnotundergone

FGMatthetimeofthesurveyvary:whileinsevenoutoftencasestherisk

isvirtuallynil(neitherthegirl’sparentsnorfamilymemberswhodidnot

migrateintendtohavehercut),inathirdofcasesariskremains,either

becauseherparents’intentionsareuncertain,orbecauseoftheexpectations

offamilyinthecountryoforigininthecaseofreturn–ariskthatmothers

areawareof.Inthelattercase,motherscanapplytwostrategiestoprevent

thecuttingoftheirdaughters:communicationaboutthelaw(notablythe

pr incipleofextraterritor i alit y)andrefusaltosendtheirdaughterstemporarily

(forholidays)totheircountryoforigin(Androetal.,2009).

V. The effects of FGM on women’s health and sexuality

IntherstdecadesofmobilizationagainstFGM,theexistenceofsystematic

andlastingconsequencesofsexualmutilationwashotlydebated(Obermeyer,

1999,2003,2005).Whilegenitalmutilationwasrecognizedtobeharmfuland

ahum anrightsviolat ion,alackofspeciccli nicalst udiesmeantthatknowledge

ofthepracticaleffectsofsexualmutilationonwomen’shealthwaslimited,

andtheveryexistenceofthoseeffectswassometimesquestioned.

Whilethemostimportantissueintheghtagainstthesexualmutilation

ofwomenistodemonstratethemassivescaleandwidegeographicaldistribution

ofthesepracticesthroughregularmeasuresoftheirprevalence,thesecondis

toprovidemedicalevidenceoftheirharmfulconsequences.Thekeyisto

provideobjectivendingsthatcancontributetothehistoricaldebatebetween

relativistandabolitionistdiscourses.

Proponentsoftheformer,inspiredbyculturalistapproaches,havetended

tominimizetheviolenceinictedonwomenwhoundergoFGM,describing

itsimplyasa“cultural”practice,whereasthoseinthelattergrouphaveoften

generalizedthemostdramaticclinicalcasesinordertoadvancetheircase.

Anarticlepublishedin1999inMedical Anthropology Quarterlysurveyingthe

literatureavailableatthetimehighlightedthelackofstatisticallyvalidempirical

ndingsonthenatureandscopeoftheconsequencesofthesepractices

(Obermeyer,1999).Obermeyercriticizedtheinternationalagendaofanti-FGM

policyforitsemphasisoncondemningthepracticeongroundsofprinciple

(78) InFrance,whiletherstprosecutionsforFGMtookplaceintheearly1980s,sanctionsagainst

thepracticebecamemoresevereinthe1990s,notablywiththehighlypublicizedtrialearlyinthe

decadeofHawaGréou,aMalianexciseusewhowassentencedtoseveralyearsinprison.Thereis

averycleargap,intermsoftheprevalenceofFGM,betweengirlsborninFranceinthe1980sand

thoseborninthe1990s(Androetal.,2009).

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ratherthanofferingdocumenteddescriptionsofwomen’ssituations.He

recognized,however,thattheconsequencesofFGMhadrarelybeenstudied,

andthuscouldbebothminimizedand/orexaggerated.GerryMackie(2003)

questionedObermeyer’sconclusions,highlightingthereductivechoiceof

sources(thefewexistingclinicalsurveysdatingfromthe1990s)thatheused

todiscreditargumentsagainstthesepracticeslargelysupportedbypublic

opinion,thenon-academicknowledgeofactorsontheground,andthe

observationsofhealthprofessionalsmobilizedontheseissues.Accordingto

Mackie,lackofknowledgeontheconsequencesofFGMwasduemoreto

taboosaroundtheissuethantotheirsupposedinnocuity.

ThemedicalconsequencesofFGMwererstinvestigatedinthe1980s

intheframeworkofclinic alstudies,butitwasnotuntiltheearly2000sthat

theresearchliteraturebecamebroadenoughtobegincharacterizingthe

healthrisksassociatedwithFGM.Moststudieswereperformedincountries

wherethepracticeish istoricallywidespread,andexaminedbotht hephysical

andpsychologicalconsequencesofFGM.Theirndingsrevealedbothdirect

consequencesofFGMandconsequencesrelatedtoinadequatehealthcare

provision–aprobleminmanyofthesecountries,notablyinmaternaland

infantcare.Thismadeitdifculttodistinguishbetweendirectandindirect

healthrisks.Inrecentyears,anumberofpublicationshavereviewedthese

studies,highlightingtheirsometimesequivocalresults,andnotablythe

difcultyofpreciselyquantifyingtheprevalenceofdifferentpathologies

(Obermeyer,2005),butconrmingthesy stematicas soci ationbetweenFGM

andanincreaseincertainhealthrisks(Bergetal.,2014;BergandDenison,

2012).TheWHOsumm arizedtheresultsoft heseclin icalstudies,developing

aty pologyoft hed ifferentconsequencesofFGM(WHO,2000,2008),which

todayservesasareferenceforthedevelopmentofpublicpoliciesonhealt hcare

forwomen.

TheWHOdistinguishesthreetypesofhealthcomplicationslinkedto

FGM:immediaterisksthatapplyatthetimeoftheactitself,long-termrisks

ofproblemsthatcanariseatanytimeinlife,andrisksthatarespecictotype

IIImutilations–thatis,toFGMinvolvingthestitchingofthelabiamajora

(Table1).

Theimmediaterisksarethoseresultingdirectlyfromthetraumaof

muti lation.Theyincludeseverepain(atthetimeofFGMandduringthehealing

process),bleeding(includinginsomecasesseverehaemorrhaging),astateof

shock(relatedtotheviolenceoftheactandtheresultingtrauma),infections

(linkedtotheconditionsinwhichthemutilationiscarriedoutandtothe

healingprocess),andnallythepotentialtransmissionofHIV(linked,again,

totheconditionsinwhichtheactisperformed).Insomecases,theseimmediate

riskscanleadtodeath.(79)

(79) InfantandchildhoodmortalitylinkedtoFGMispoorlymeasuredandisinvisibleinmortality

statisticsfortheaffectedcountries.

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Therearemanylong-termrisks,andwhiletheassociatedproblemsdonot

occurinallcases,theyareextremelyfrequent.Girlsandwomencansufferfrom

chronicpainandkeloids.(80)Genital,pelvic,andurinaryinfections,aswellas

urinarypathologies,canarise fromchildhoodonward.Infectionsofthe

reproductivesystem,genitalherpes,sexuallytransmittedinfections,andthe

riskofHIVtransmissionareaddedwhenwomenbecomesexuallyactive.Overall,

therisksofsexualdysfunctionarehigh,rangingfromlackofsexualdesireto

systematicpainduringintercourse.Last,obstetriccomplications(Caesarean

delivery,post-partumhaemorrhaging,tearing,andevenobstetricalstulae)are

widespread.Risksoflifelongpsychologicaleffectshavealsobeendocumented.

Finally,risksspecictoinbulationincludemajorurinaryandmenstrual

problems,forceddeinbulationduringsexualintercourseorchildbirth,and

chronicsexualpainanddysfunction.

TheWHOdevelopedthisoverallclinicalpicturebasedonareviewof

variousstudiesperformedoverthelasttwodecades.Ithasstronglysupported

thecampaigntoendFGMinregionswhereargumentsbasedonwomen’sand

children’srightscarrylittleweight.WhiletheWHOwasabletocreateadet ailed

overviewoftheharmfuleffectsofFGM,notallofthesehealthrisksare

sufcientlydocumentedandstudiedtomeasuretheirrelativeimportance.

However,somerecentstudie sonlarges amplesofwomenorgirlsofferevidence

beyondthatprovidedbyclinicalcasestudies.

1. Immediate complications

Immediaterisksandcomplicationsaredifculttoanalyseonalargescale

giventheconditionsinwhichFGMisgenerallypracticed.Thefewavailable

studiessuggestthatcomplicationsareunder-reported(ElDareer,1983).Inall

cases,theconsequencescanonlybestudiedsometimeaftertheevent,and

thetypeofinformationcollectedissubstantiallybiasedbymemoryeffects,

amongbothgirlsaskedabouttheirownexperienceandparentsaskedabout

theirdaughters.Inarecentreview,Bergandcolleagues(2014)estimated,on

thebasisofavailablereliablesurveys,(81)thatthemostcommonlyreported

consequencesareexcessivebleedingandurineretention(differentstudies

foundth atbetween5%and62%ofwomensufferthesecomplications),followed

bygenitaltissueswellingandhealingproblems(2%to27%ofwomen).

2. Other physical and psychological complications

Severalstudieshaveconrmedtheexistenceofstatisticallysignicant

relationshipsbetweenFGMandtheprevalenceofinfectionsandurogenital

(80) Anovergrowthofscartissuethatcandevelopinthelocationofthecuttingandcreatechronic

problems.

(81) Thatis,representativesurveysonlargesamples,suchasthefewDHSsurveysthathaveincluded

amoduleonthisquestion(CentralAfricanRepublicin1995,Chadin2004).

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problemsatallages(Almroth,Bedrietal.,2005;Androetal.,2014).Urinary

infectionsandpainordifcultywithurinationareparticularlycommon.In

their2014meta-analysis,RigmorBergandcolleaguesestimatedthatthese

urinaryproblemsarethreetimesmorecommonamongwomenwhohave

undergoneFGMthaninotherwomen(Elmusharaf,2006a;Okonofuaetal.,

2002).Similarly,mycoses/fungalinfectionsandtheassociatedsymptoms

(vaginaldischargeanditching)aremorecommonamongwomenwithFGM,

andparticularlythosewhohavebeeninbulated.Theyarealsopresentin

womenwhoundergoamedicalizedFGM(Almroth,Bedrietal.,2005).Other

physicalsequelaearerarer,andextantstudieshavenotdemonstrateda

statistic allysig nica ntrelationshipbetweenFGMandcy sts,abscesses, stul ae,

orvaginalobstruction(Bergetal.,2014).

ThelinkbetweenFGMandthetransmissionofSTIsandHIVisalsonot

yetclearlyestablished.Thecase-controlstudybyElmusharafandcolleagues

(2006a)inSudanconcludedthatthedifferencesbetweenthecases(infected

women)andcontrols(non-infectedwomen)weresmallandthatFGMstatus

hasneitheranegativenorapositiveeffectontherisksofinfection.Other

studiesonthetopichaveyieldedsimilarresults(Bergetal.,2014).

Withregardtopsychologicalconsequences,manystudieshavebeencarried

outbuttheyhavenotyieldedrobustresults.Theyarepredominantlybased

oncasestudies,andcannotbeusedtoassesstheprevalenceofpsychological

disordersamongwomenwit hFGMortoest ablishalinkbet weensuchd isorders

andFGMitself.Thereisanexception,however,withregardtowomenwho

havemigratedtoEurope:Vloeberghsandcolleagues(2012)inaquantitative

studyonpsychologicaldisordersin66migrantwomenwhohadundergone

FGM,showedthatoneinsixsufferedfrompost-traumaticstressdisorder,and

thatathirdsufferedsymptomsofdepressionandanxiety.Asurveyofmigrant

womeninFrancealsoshowedanincreasedriskofsymptomsof“ill-being”,

withfatig ueandan xietyreportedbymorethanaquarterofwomenwithFGM

(Andro etal.,2014).

3. Obstetric complications

Sincethe2000s,theWHOhasplacedparticularemphasisontheissueof

obstetriccomplicationsinitseffortstocombatFGM,andthisisthemost

widelystudiedaspectofthepractice.Thesurveycarriedoutbetween2001

and2003byBanksandcolleaguesin28maternityunitsinsixAfrican

countries,(82)coveringasampleof28,393mothers,producedsolidresultson

theobstetricconsequencesofFGMincountrieswhereithashistoricallybeen

practiced(WHOStudyGrouponFemaleGenitalMutilationandObstetric

Outcome,2006).Thewomenwereexaminedbeforedeliveryandfollowedup

untiltheirreturnhome.Thismajor,large-scalestudyshowedthatwomenwith

(82) BurkinaFaso,Ghana,Kenya,Nigeria,Senegal,andSudan.

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FGMareatgreaterriskthanotherwomenofCaesareansection,postpartum

haemorrhage,respiratorydistressinthenewborn,neonataldeath(whichis

twiceasfrequentinwomenwithFGM),lowbirthweight,andanextended

hospitalstay.Theserisk sarehighestamongwomenwhoh aveundergonet y pe

IIImutilation.

Thesendingsreectnotonlythegreaterhealthriskssurrounding

childbirthinwomenwithFGM,butalso,moregenerally,theoftenpoor

conditionsofhygieneandsafetyinwhichthesewomengavebirth(Ndiayeet

al.,2010).However,astudyofwomenwithFGMwhogavebirthinahigh-

qualityhealthcareenvironmentinSwitzerlandfoundthatsomehealthrisks

remain,notablytherisksofemergencyCaesareansectionanddeeptears

(Wuestetal.,2009).Risksoftearingduringdeliveryarealsosignicantin

France(Androetal.,2014).AveryrecentstudyinaSwissclinicspecialized

incareofwomenwithFGMshowed,however,thattheserisksarelowerwhen

themedicalteamhasspecializedknow-how(Abdulcadiretal.,2015).

4. Impact on sexual life

AcademicinterestintheconsequencesofFGMforwomen’ssexualityis

recentand,asyet,fewsolidresultsareavailable,asresearchonthesexual

function(83) ofwomeningeneral,andwomenwithFGMinparticular,isvery

heterogeneous(BergandDenison,2012).Thescienticapproachestowomen’s

sexualityareheavilyinuencedbysocialnormsandrepresentations(Gagnon

etal.,2008),andthereisnogeneralconsensusonthechoiceoftoolsfor

measuringqualityofsexualfunctionandsexuallife.Thismakesitdifcult

tostudythesexualconsequencesofFGM.TherststudiesbyCataniaand

colleagues(Cataniaetal.,2007),inwhichseveralgroupsofwomenwere

compared,showedthatmeasuringdifferencesindegreeofsexualsatisfaction

isacomplexexercise.

Afewresultshavenowbeenvalidated,andlinksbetweencertainsexual

dysfunctionsandFGMhavebeenhighlightedinseveralstudies(Bergand

Denison,2012).Bothsexualdesireandsexua lsatisfactionarelowerinwomen

withFGM,andpainduringintercourseissignicant lymorecommon.Acase-

controlstudywithmigrantwomeninSaudiArabiagaveevidenceofdifculties

withorgasm,lubrication,andsexualsatisfactionamongwomenwithFGM

(AlsibianiandRouzi,2010).Acase-controlstudyinFrancealsohighlighted

clearnegat iveeffect sonthesexuallifeofwomenw ithFGMcomparedtoother

womenwithcomparablesocialcharacteristics(migrantsordaughtersof

migrants):theyweremorelikelytoreportpainorburningsensationsduring

intercourse,chroniclackofsexualdesire,andlackofsatisfactionwiththeir

sexuallifemoregenerally(Androetal.,2014).

(83) Thenotionofsexualfunctionecompassesthebio-physiologicalfunctioningofthegenitalorgans

aspartofthe“humansexualresponsecycle”(Giami,2007).

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Thesestudiesshowthatsexualmutilationscreaterisksforwomen’s

healththatpersistthroughouttheirlives,bothinchildhoodandlater

duringsexualandreproductivelife.Moststudiesfocusonadultwomen,

andlittleisknown(andthenonlyretrospectively)abouttheproblems

thatgirlsexper iencedur i ngchildhoodandpubertyduetoFGM(Aboyeji

andIjaiya,2003;Ekenzeetal.,2007).Researchhasthusfarconcentrated

onpathologieslinkedtosexualandreproductivelife,leavingasidehealth

risksinchildhood.

VI. The role of the medical sector

Themedicalsectorhastakenondiametricallyopposedroleswithregard

toFGMindifferentregionsoverthelasttwodecades.Ontheonehand,in

ordertominimizehealthrisks,healthprofessionalshavebeenincreasingly

involvedinperforminggenitalmutilationonchildreninaccordancewith

familytraditions.Physiciansandotherhealthprofessionalsareingrowing

demandforsuc hoperationsonbothboysandgirl s.Indeed,soci altransfor m ations

haveplacedhealthprofessionalsinthespotlightwithregardtoFGM,notonly

inthecountriesoforiginwheretheyaregraduallyreplacingtraditional

circumcisers(exciseuses),butalsoincountriesofimmigrationwheretheyhave

discoveredtherealityofthisphenomenon.Moreover,themedicalspherehas

beguntooffertreatmenttogirlsandwomenforthesequelaeofFGM(Momoh

etal.,2001).Thesemedicalservices,generallyreferredtoasrehabilitationor

reconstruction,aimtotreatwomenincaseswheretheadverseeffectsofFGM

ontheirqualityoflifehavebeenrecognizedanddenounced(Abdulcadiret

al.,2011).

1. The medicalization of FGM and mobilization against its spread

FollowingtheTechnicalConsultationontheMedicalizationofFemale

GenitalMutilation/CuttingorganizedbytheUNFPAin2009inNairobi,all

internationalorganizationshavecondemnedtheinvolvementofhealth

professionalsinFGM,inanycontext,whetherinhospitals,otherhealthcare

institutions,orelsewhere(UNFPAetal.,2010).Thisinternationalposition

statementwasneededtocountertheexpandingmedicalizationofFGM(Serour,

2013).

MedicalizedFGMhas substantially increasedinrecentyears,

particularlyinEgypt,Kenya,Guinea,Nigeria,andSouthSudan(inAfrica),

aswellasinYemenandIndonesia.Inthesecountries,between30%and

80 %ofFGMproceduresarecarriedoutbyhealthprofessionals(UNICEF,

2013,2015).Thisissueisparticularlyacuteintheyoungestcohorts,where

thetrend isrecentand worrying,asitmay havethepotentialto

fundamentallyunderminethediscourseagainsttheseharmfulpractices.

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ThesenewformsofFGMinvolvinghealthprofessionalshaveexpanded

sincetheearly2000s(Shell-Duncan,2001),weakeningthecaseforits

eradication(Shell-Duncan,2008).

Insomecountries,healthprofessionalshavestartedtopracticegenital

cutting,andeveninbulation,ongroundsthatitreducestheincidenceof

complications.Thesemedicalizedactshavealso,inmanycases,becomenon-

negligiblesourcesofincomeforpractitioners,attheexpenseoftraditional

circumcisers.Insomecountries,suchasEgyptandMalaysia,governments

andcertainassociationshaveunfortunatelyconsideredthatperformingFGM

inthiswayoffersanacceptablesolution.AsSerour(2013)recalls,inthelate

1990ssomehealthcarepersonnelbegantomoreorlessexplicitlyrecognize

andacceptthemedicalizationofFGM.

(84)

Itwa son lyfollow ingt hemobilization

oftheInternationalFederationofGynecologyandObstetrics(FIGO)thatthis

medicalizationwasgraduallyoutlawedinmostcountries,withthenotable

exceptionofIndonesia.(85)

Thisnewsituationledtom ajord i scussionwit hintheanti-FGMmovements.

Themainquestionatissuewaswhetherornottorecognizethismedicali z ation

asanacceptablestrategy,notablyinregionswheresocialresistancetothe

completeabandonmentofthepracticeisstrong(Shell-Duncan,2001).While

thiscouldbeseenasanintermediatepaththatlimitshealthriskstowomen,

themajorityofmovementsinvolvedintheghtagainstFGMopposedthis

proposal,arguingthatrecognizingthemedicalizationofpracticesthatviolate

thephysicalintegrityofgirlsandwomen,andthustheirr ights,couldlegitimate

themandcontributetotheirpersistence.

However,beyondtheseclearlyestablishedpositionsofprinciple,thereis

littleresearchintotheroleofhealthprofessionalsintheabandonmentor

perpetuationofFGM.AfewstudiesperformedinEgypt(Abdelshahidand

Campbell,2015;ModrekandLiu,2013;ModrekandSieverding,2015;Rasheed

etal.,2011)haveshownthatwhilefamiliesareincreasinglylikelytorelyon

doctors’opin ionswhenmakingadeci sionaboutamedicalizedFGMprocedure,

physicianstendnottorefusewhattheyconsidertobealegitimateparental

request.Theyalsohighlighttheeconomicaspectofthispractice,whichisa

complementarysourceofincomefort hemedicalsector.Thesestud iesconclude

thatincountrieswheremedicalizationisalreadyveryadvanced,thetraining

ofprofessionalsw i llbeacent ralelementintheabandonmentofthesepr act ice s.

(84) TheEgyptianMinistryofHealthrecognizedthelegalityofthesepracticesforhealthprofessionals

in1994,MédecinsSansFrontièresheldanambiguouspositionforashorttime,andtheAmerican

AssociationofPediatricianstookahighlycontroversialstandpoint,promotingmedicallyexecuted

FGMonAmericansoilasawaytoreducehealthrisksforgirlswhowouldotherwiseundergoFGM

duringavisittotheirfamilies’countryoforigin.

(85) AfteranunsuccessfulattempttoprohibitmedicalizedFGMin2006,in2010theIndonesian

Mi nistryofHea lth iss uedadec re eauthor i zin gh eal thprofe ssion als (p hy sician s,mid wives,andt rai ned 

nurses)topracticeFGMinamedicalenvironment(publicandprivate).Followingacampaignagainst

thisdecreebytheWomen’sCommissionandtheCommitteeontheRightsoftheChild,thedecree

wasrepe aledin2014.However,intheabsenceofsanct ions,thepracticecontinues(UNICEF,2015).

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2. The particular case of reinﬁbulation

Theterm“reinbulation”referstocaseswherest itchingisre-appliedafter

childbirthinwomenwhohavepreviouslyundergonetypeIIIFGM.This

customarypracticeisstillcommoninanumberofcountries.Whilethe

reliabilityofdataonthisissueispoor,thenumberofwomenreinbulated

follow i ngchildbir thisestimatedatbet ween6.5and10.4million(Serour,2010).

Inthecountrieswheretheseproceduresaremostcommonlypracticed,they

havealsobecomeincreasinglymedicalized,andareoftenpresentedasrequests

madebythewomenthemselvesatthetimeofchildbirth.Hereagain,adiscourse

hasdevelopedt h ataimstojusti fythemedic alizationofreinbulationi nterms

ofriskreduction,notablyintheshortterm(infections,haemorrhage,etc.).But

thefewstudiesonthequestionhaveconrmedthatitisofnobenet,andis

associatedwithmajormedicalcomplicationsforwomen(Serour,2010).As

withthemedicalizationofFGM,thispracticeisdifculttochallenge,given

thestrengthofsocialnorms,butalsotheassociatednancialinterests.

Reinbulationconstitutesanethicalissue,bothincountriesoforigin

andcountriesofimmigration;ithasbeentheobjectofmajordebatein

medicine,andnotablyinobstetricgynaecology,inrecentyears.These

proceduresraisecomplexethicalquestions,ashealthprofessionalsare

subjectedtocontradictoryinjunctions,bet weenthedemandsofhealthpolicy

andprofessionalresponsibilityonthehand,andquestionsofconsentand

freew illontheother:arequestmadebyanadultwomanabletogiveinformed

consentcannotbeconsideredinthesamewayasthecaseofalittlegirl

subjectedtoFGM.However,practitionersmustalsotakeintoaccountthe

socialpressureth atundoubtedlyweighsonthesewomen,whosefreedomof

consentmaybelimited(CookandDickens,2010).CookandDickensargue

thataphysician’srefusaltoperformreinbulationcanneverbeconsidered

equivalenttocaseswhereadoctordeclinestoperformaprocedureongrounds

ofprofessionalconscience,asseeninsomecountrieswithregardtosterilization

andabortion,giventhatclinicalanalysesclearlydemonstratetheadverse

effectsofreinbulation(Serour,2010).

3. Rehabilitation operations and their slow recognition

Differentformsofsurgicalinterventiontoimprovethesituationofwomen

affectedbythesequelaeofFGMhavebeendevelopedsincethe1990s.Some

havebeenevaluatedinclinicalstudiesandarenowmedicallyrecommended,

andvalidatedbytheWHO.Thisisthecasefordeinbulationandvulvar

reconstructiontotreattheeffectsoftypeIIIFGM,whichincludesstitchingof

thelabiamajor a.Treat mentsfortheeffect sofclitoridectomy,whichhavebeen

developedinparallel,arestillbeingevaluatedbynationalandinternational

healthauthorities,andtherearefewclinicalstudiesasyet.Francehastaken

aleadingroleinthisdomain.Itist heonlycountr ytohavedevelopedtechniques

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ofsurgicalrepairthatarerecognizedandreimbursedbythenationalhealth

insurancesystem,andthatareavailableinmanypublichospitals.

Vulvar reconstruction and deinbulation

Deinbulationisareconstructivesurgicalprocedureperformedonthe

scartissuecausedbythestitchingofthelabiamajoraduringinbulation.The

openingofthisscartissuefreesthevagina,theurethralmeatus,andthe(often

intact)clitoralglans,allowingsubstantialimprovementsinthepatient’s

urogenitalandsexualhealth(Nouretal.,2006).

(86)

Boththesurgicalactin

itselfandpostoperativemanagementaregenerallystraightforward.These

operationscantakeplaceatdifferenttimesinwomen’slives.Insomecases,

therequestismadebywomenwhohavenotyetinitiatedadultsexuallifeand

whowishtolimitorpreventpossiblecomplications.Inothers,deinbulation

isperformedduringpregnancyoratthetimeofchildbirth.Inbothcases,

mult idisciplinar ycareforwomenwhochoosedeinbulat ioniscrucial,astheir

choiceoftenreectsadesiretodistancethemselvesfromorevenchallenge

familypracticesandcommunitysocialnorms(Abdulcadiretal.,2011).

Clitoral repair

WhiletheWHOrecommendsdeinbulationoperationsforwomenwho

haveundergonetypeIIImutilations,thecurrentsituationwithregardtoclitoral

repairsurgeryisdifferent.Thistypeofoperationremainsrareanditsclinical

evaluationisongoing(Abdulcadiretal.,2015).Itispracticedinahandfulof

countries,includingSenegal,BurkinaFaso,andnotablyCôted’Ivoire(Ouedraogo

etal.,2013;ThabetandThabet,2003),aswellasinFrancewhereitisavailable

inabout20hospitalsandhasbeencoveredbythenationalhealthinsurance

systemsince2004(Androetal.,2010;AntonettiNdiaye etal.,2015;Foldès et

al.,2012;FoldèsandLouis-Sylvestre,2006;Villani,2009;VillaniandAndro,

2010).

ClitoralsurgeryfollowingFGMwasdevelopedinthelate1990sbyPierre

Foldès,aFrenchurologist,asahumanitarianmedicalinterventionformutilated

womenwithpainfulcomplications.Theoperationconsistsinfreeingtheclitoral

stumpandrepositioningitinitsanatomicalposition(FoldèsandLouis-Sylvestre,

2006).Thisoperationiscarriedoutinresponsetoawiderrangeofneeds:

painfulsequelae,butalsodemandsforimprovedqualityofsexuallifeand/or

expectationsanddemandsforphysicalintegrity(“tobeacompletewoman”).

Thesurgicaltechniqueandinitialresultshavebeendescribedinvarious

publications,mainlyfromFrance(AntonettiNdiaye etal.,2015;Foldès etal.,

2012;FoldèsandLouis-Sylvestre,2006).Theyshowthatclitoralsurgery

(86) Thestudy,carriedoutbyNawalNourandcolleaguesintwoBostonhospitalswith40deinbulated

womenwhowerefollowedupbytelephone6monthsand2yearslater,showedthattheydidnot

experienceanypostoperativecomplications,thattheywouldrecommendtheoperationtootherwomen

withFGM,thattheyaresatisedwiththeresultsoftheoperation,andthattheyhavesatisfying

sexualrelationswiththeirspouses(Nour etal.,2006).

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signicantlyimprovespatients’qualityoflifebutthatitisprobablynotan

appropriatesolutionforallwomen.

The2,938patientsoperatedonbyPierreFoldèsbetween1998and2009

representthelargestanalysedandpublishedseriesof“repairs”(Foldès etal.,

2012).Patients’requestsaregenerallypartofamulti-factorialprocessandare

sometimesformulatedwithdifculty.Thethreemainexpectationsarelinked

totreatmentforpain,improvementofsexualfunction,andamorecomplex

dimensionof“becomingacompletewoman”.Inthestudy cohort, the

overwhelmingmajorityofpatients(821outof840)followeduponeyearafter

surgeryreportedthattheseexpectationsweresatised.(87)

Theotherstudiesexaminesmallerseries.Twoadoptawiderperspective,

analysingtheresultsnotonlyofthesurgicalintervention,butalsoofthe

accompanyingmultidisciplinarycaresystem(AntonettiNdiaye etal.,2015;

Merckelbaghetal.,2015).Onecovers270womenwhoreceivedcarebetween

2007and2012,andtheotheraseparatesampleof169womentreatedbetween

2006and2011,intwohospitalsintheParisregion.Lessthanhalfofthe

patientsultimatelyhadthesurgery.Thesetwostudiesshowedthatalarge

proportionofwomenrequestingsurgeryhaveexperiencedsexualtraumaother

tha ngenit almutilation(sexualassaultandviolence).Theyconrmt h at“repair”

followingFGMisnotamatterofsurgeryalone,butthatsurgerydoesimprove

thequalityofsexuallife.

InFr ance,t heE xci sionetHandicap(FGManddisability)survey,ageneral

populationsur veycarriedouti n20 07-2009,alsoshowedthatat hirdoffem ale

respondentswithFGMreportedbeinginterestedinsurgicalreconstruction

andthatthefewwhohadundergonethesurgery(21outof685women)were

satisedwiththeresults(Androetal.,2009,2010).

VII. Conclusion: the importance of further research

ResearchonFGMhasbeenexpandingsincetheearly1990s.Studieshave

shedlightonthescaleofthisphenomenonanditseffectsonwomen’ssexual

andreproductivehealth.Recognitionoftheadverseeffectsofgenitalmutilation

onobstetrichealthisthemainfactorbehindworld-wideeffortstoeradicate

thesepracticesandtoplacethemontheinternationalagendaofwomen’sand

children’srights(UNFPA,2014).Themostrecentstudieshavefocusedmore

specicallyontheconsequencesofthesepracticesforwomen’shealthandon

thesocialdynamicsatworkaroundtheirpersistenceorabandonment,and

haveexaminedchangesovertimeinsocialandfamilypracticesinacontext

ofcontinuousreinforcementofanti-FGMpolicies.Amongongoingresearch

pr ior ities,fourtheme scanbeidentied.Twoconcerntheanalysi sandproduction

(87) Inphysiologicalterms,99%ofwomenexperiencedanoticeabletransformationoftheirclitoris;

4%requiredasecondoperation.

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ofdataonthetopic:rst,fur therexplorationofthedetermi nant softhepractice

andofresistancetoitsabandonment,andsecond,abetterunderstandingof

theglobalizationofthephenomenonthroughmoreaccuratemeasuresin

countrieswhereitisnotwidelyrecognizedandincountrieswithmigrant

populations.Thethird,moremedicalthemeistheadvancementofknowledge

onthehealthconsequencesofFGM.Thefourthandnalthemeconcerns

publicaction,andtheappropriationanddenitionofinternationalpolicies

bythewomenconcerned.

1. Improving analysis of available data

Alargebodyoffactualstatisticaldataonfemalegenitalmutilationhas

beenproducedinrecentdecades,undertheaegisofinternationalorganizations.

Theseeffor t shaveyieldedsoundknowledgeoft heprevalenceandcharacteristics

ofthesepracticesin30countries,oftheirdeterminantsandconsequences,

andofchangesinperceptionsovertime.However,mostanalysesaimedat

understandingthemechanismsofreproductionarestilllargelydescriptive.

Moresophi stic atedst atisticalapproachesarenowneeded,notablyincountr ies

wherecomparabledat aareavailable,u singmultivariateandmultilevelanalyses

tobetterunderstandtheweightandparticularrolesofthevariousdeterminants,

whichmayvaryacrossdifferentcontexts.Socialnormsactthroughthefamily

environment,theneighbourhoodorvillage,theregion,andthecountry(of

originand/ordestination),andtheinterrelationshipsbetweenthesedifferent

levelsmustbestudied.Oncethesecontextualanalyseshavebeencarriedout,

itwillbecomepossibleto explorethefactorsthatcontributeto social

transformation,suchasthoseclassicallyusedtomeasurewomen’sautonomy

(polygamy,moderncontraceptivepractices,etc.).Betterintegrationofmen’s

behavioursandopinionsintomodelsandanalysescouldshedlightontheir

role,whichistoooftenneglected.Thespecicimpactofmigration,bothrural-

to-urbanandtransnational,mustalsobestudiedinmoredetail.

2. Developing data collection

Thesituationincountriesofimmigration,wheretherelevantpopulations

arerecent,particularlyvulnerableandhavelowsocialvisibility,andwhereFGM

remain samarginalphenomenon,rem ainslargelyunk now n.Forexample,l itt le

isknownabouttheprevalenceoffemalesexualmutilationinEurope.Thereis

currentlynostandardizedmethodforestimatingthescaleofthephenomenon

inthevariousmemberstatesorforproducingcomparabledata.Developing

commondenitionsandmethodologiesforestimatingthenumberofwomen

affectedbyFGMineachcountryisoneoftherecommendationsinthenal

reportoftheprojectonFemaleGenitalMutilationintheEuropeanUnionand

CroatiapublishedbytheEuropeanInstituteforGenderEquality(EIGE,2013).

Thesituationincountriesofimmigrationseemstoberelativelysimilartothat

ofAfricancountrieswithlowlevelsofFGM(prevalenceunder5%,asinCameroon,

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Uganda,Niger,Ghana,andTogo).Thedevelopmentofacommonmethodology

toproducecomparabledataforallcountriesintheworldisafundamental

elementintheghttoeliminatethesepractices,andtoimplementpolicieson

careandsupportforwomenwithFGM.Thesedataareneededbypublicauthorities

(health,education,justice)andcivilsocietyactors.Suchimprovementsinthe

toolsforguidingpublicpolicywouldhelptoimprovethesituationofwomen

andgirlswhohavebeensubjectedtothisharmfultraditionalpractice.

3. Greater focus on the health effects of FGM

ThetypologydevelopedbytheWHOhasmadeitpossibletosurveyand

quantitativelydocumentthemedicaleffectsofFGM.Despitenotableadvances

inthelasttwodecades,asBergandcolleagueshaveshown,manypathologies

remainpoorlystudied.Whiletheirexistencehasbeendocumentedincase

studies,knowledgeoftheirincidenceandtheirconnectiontoFGMremains

limited.Thi stypolog yistheoutcomeofclinicalstudiescar riedoutoverseveral

decadesundertheaegisoftheWHO,andofoftenheateddebateswithina

multidisciplinaryresearchcommunitythatcombinesanthropological,medical,

political,andmoralapproaches.ThequalicationofFGMasa“harmfulpractice”

byinternationalorganizations(WHO,UNICEF,UN,UNFPA,UNHCR,UNAIDS)

hashadacontentioushistory,generatingmuchinternationaldebate.Today,

politicaldiscourseagainstthesepracticesfocusesmainlyontheirperinatal

effects.TheseeffectsareindeeddramaticinthecountrieswhereFGMisa

traditionalpractice,muchlesssoincountriesofimmigrationwherethe

medicalizationofchildbirthconsiderablyreducestherisks.Inthesecountries,

thegreatesthealtheffectforwomenwithFGMisthepoorqualityoftheirsexual

life.TheresultsofmedicalresearchonthepathophysiologyofFGMsuggestthat

anewsystemforcategorizingtypesofsexualmutilationisneeded.Butinthe

countrieswherethispracticeistraditional,therearemajorbarrierstoexplicit

discourseonimprovingwomen’ssexualhealth,andhealthprofessionalsare

reluctanttotakethelead.Medicalstudiesshowthatsexualmutilationleadsto

healthrisksthatpersistthroughoutlife,witheffectssometimesappearinglong

aftertheactitself.Mostclinicalsurveysarecarriedoutinadultwomenandfocus

mainlyonpathologiesinsexualandreproductivelife,thusneglectingrisksin

childhood.Littleiscurrentlyknownaboutthehealthproblemssufferedbygirls

inchildhoodandpubertyfollowinggenitalmutilation.

Healthprofessionalswillhaveafundamentalroleintheeradicationof

FGMinthecomingdecades,bothaskeyactorsinpreventionandasexperts

inthecareandtreatmentofaffectedwomen.Theirtrainingwillbecentralto

theeradicationofthesemutilations.

4. Implications for women’s rights

TheghttoeradicateFGMhasbeenbuiltaroundtheoriesofsocial

conventionsandsocialchange.After30yearsofmobilization,itisstilldifcult

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todeterminewhetherthisapproachisappropriate.Thepaceofsocialchange

isrelativelyslow,andmeasuringchangeswilltaketime.Theincreasingly

globalscaleofthephenomenon,li nkedtothecirculationofperson sandideas,

isnowbecomingclear,alongwithanewawarenessoftheextentofthese

practicesinregionswheretheywerepreviouslyunderestimated.Theght

againstFGMwillbemultifaceted:itmustbeadaptabletodiversesituations,

bothinthecountriesoforiginandincountriesofimmigration.Butwemust

notforgetthateffortstoeradicatethepracticemaybackreiftheyleadtothe

impositionofhegemonicsocialnor m s(Vissandjéeetal.,2014).Thetwoposit ions

consistingofdismissingculturalpracticesas“barbaric”ontheonehand,or

dismissingengagementinfavourofwomen’srightsas“imperialist”onthe

other,areultimatelycounterproductive.Theformerdisregardsoppositionto

FGMwithintheaffectedpopulations,whilethelatterneglectsthepower

asymmetrybetweenNorthandSouthininternationaleffortstocombatthe

practice.Whileinternationalorganizationscontinuallystressthatthepriority

istoeradicateFGM,andtheglobalizationofmigratoryowshastransformed

thepracticeintoaworld-widepublichealthissue,developingashared

internationaldiscourseremainsamajorchallenge.Althoughthereisconsensus

ondefendingchildren’srightsandprotectingmothers,women’srighttoa

fulllingsexualityisstillsubjecttodebate.Alackofknowledgeonwomen’s

sexualityoftenlimitsthereachofdiscourseagainstFGMbasedonarguments

aboutitsharmfuleffectsonsexuallife.Itisthusclearthatacriticalanalysis

oftheconstructionofinternationalargumentsinthehistoricalghtagainst

FGMisneeded.Thisisdoubtlessanecessarysteponthewaytoadoptinga

newperspectiveonthisformofgenderviolence:onethatisbasedonthe

perceptionsandfeltexperiencesofthewomenconcerned,andnotablytheir

capacityforresilience,andthatceasestorelyexclusivelyonformsofmedical

andanthropologicaldiscoursethattoosystematicallyignorewomen’sown

pointsofviewontheirsituation.Wemustthereforecontinue,inthelightof

recentresearch,todeconstructthestereotypicalgureofthe“cutwoman”

understoodasahomogeneousandobjectivecategory,andseekinsteadtograsp

thediversityofsituationsandharmfuleffectsthatthisactcanhaveonthelife

trajectoriesofthesewomen,andtherebymovetowardsitseradication.

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AppENdiCES



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Document A. Speciﬁc questionnaire on FGM

in the most recent Demographic and Health Surveys (DHS)

NO.

GC1 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 GC3

(2) NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

GC2 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

GC3 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 GC9

GC4 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 GC6

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

GC5 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

GC6 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

(3) NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

GC7 AGE IN COMPLETED YEARS . . . . . . . .

AS A BABY/DURING INFANCY . . . . . . . . . . . . . 95

DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

GC8 TRADITIONAL

(4) TRAD. CIRCUMCISER . . . . . . . . . . . . . . . . . . . 11

TRAD. BIRTH ATTENDANT . . . . . . . . . . . . . 12

OTHER TRAD. 16

HEALTH PROFESSIONAL

DOCTOR . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

NURSE/MIDWIFE . . . . . . . . . . . . . . . . . . . . . . 22

OTHER HEALTH

PROFESSIONAL 26

DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

GC9

(5) GC16

QUESTIONS AND FILTERS CODING CATEGORIES SKIP

FEMALE GENITAL CUTTING/MUTILATION FOR WOMAN'S QUESTIONNAIRE (1)

Now I would like to ask some questions about a

practice known as female circumcision. Have you ever

heard of female circumcision?

SEC.

HAS ONE OR MORE

LIVING DAUGHTERS

BORN IN 2000 OR

LATER

HAS NO LIVING

DAUGHTERS BORN

IN 2000 OR LATER

Have you yourself ever been circumcised?

In some countries, there is a practice in which a girl

may have part of her genitals cut. Have you ever heard

about this practice?

CHECK 213, 215 AND 216:

(SPECIFY)

Was your genital area sewn closed?

Was the genital area just nicked without removing any

flesh?

Now I would like to ask you what was done to you at

that time. Was any flesh removed from the genital

area?

IF THE RESPONDENT DOES NOT KNOW THE

EXACT AGE, PROBE TO GET AN ESTIMATE.

How old were you when you were circumcised?

Who performed the circumcision?

(SPECIFY)

W-2

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277

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Document A (cont'd). Speciﬁc questionnaire on FGM

in the most recent Demographic and Health Surveys (DHS)

GC09A

(5)

GC10

(5)

BIRTH BIRTH BIRTH

HISTORY HISTORY HISTORY

NUMBER . . NUMBER . . NUMBER . .

NAME NAME NAME

GC11 YES . . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1

NO . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2

(GO TO GC11 (GO TO GC11 (GO TO GC11

IN NEXT COLUMN; IN NEXT COLUMN; IN FIRST COLUMN

OR IF NO MORE OR IF NO MORE OF NE W

DAUGHTERS, DAUGHTERS, QUESTIONNAIRE; OR IF

GO TO GC16) GO TO GC16) NO MORE DAUGHTERS,

GO TO GC16)

GC12 AGE IN AGE IN AGE IN

COMPLE- COMPLE- COMPLE-

TED YRS . . TED YRS . . TED YRS . .

DON'T KNOW . . . . . . . . 98 DON'T KNOW . . . . . . . . 98 DON'T KNOW . . . . . . . . 98

GC13 YES . . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1 YES . . . . . . . . . . . . . . . . 1

(3) NO . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2 NO . . . . . . . . . . . . . . . . 2

DON'T KNOW . . . . . . . . 8 DON'T KNOW . . . . . . . . 8 DON'T KNOW . . . . . . . . 8

GC14 TRADITIONAL TRADITIONAL TRADITIONAL

(4) TRADITIONAL TRADITIONAL TRADITIONAL

CIRCUMCISER . . 11 CIRCUMCISER . . 11 CIRCUMCISER . . 11

TRAD. BIRTH TRAD. BIRTH TRAD. BIRTH

ATTENDANT . . 12 ATTENDANT . . 12 ATTENDANT . . 12

OTHER TRAD. OTHER TRAD. OTHE R TRAD.

16 16 16

HEALTH PROFESSIONAL HEALTH PROFESSIONAL HEALTH PROFESSIONAL

DOCTOR . . . . . . . . 21 DOCTOR . . . . . . . . 21 DOCTOR . . . . . . . . 21

NURSE/MIDWIFE . . 22 NURS E/MIDWIFE . . 22 NURSE/MIDWIFE . . 22

OTHER HEALTH OTHER HEALTH OTHER HEALTH

PROFESSIONAL PROFESSIONAL PROFESSIONAL

26 26 26

DON'T KNOW . . . . . . . . 98 DON'T KNOW . . . . . . . . 98 DON'T KNOW . . . . . . . . 98

GC15 GO BACK TO GC11 IN GO BACK TO GC11 IN GO TO GC11 IN

NEXT COLUMN; OR, IF NEXT COLUMN; OR, IF FIRST COLUMN OF NEW

NO MORE DAUGHTERS, NO MORE DAUGHTERS, QUESTIONNAIRE; OR IF

GO TO GC16. GO TO GC16. NO MORE DAUGHTERS,

GO TO GC16.

Is (NAME OF DAUGHTER)

circumcised?

How old was (NAME OF

DAUGHTER) when she was

circumcised?

IF THE RESPONDENT DOES

NOT KNOW THE AGE,

PROBE TO GET AN

ESTIMATE.

FEMALE GENITAL CUTTING/MUTILATION FOR WOMAN'S QUESTIONNAIRE (1)

SECOND-TO-YOUNGEST

LIVING DAUGHTER

NEXT-TO-YOUNGEST

LIVING DAUGHTER

YOUNGEST LIVING

DAUGHTER

BIRTH HISTORY NUMBER

AND NAME OF EACH LIVING

DAUGHTER BORN IN 2000

OR LATER.

Now I would like to ask you some questions about your (daughter/daughters).

CHECK 213, 215 AND 216: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER AND NAME OF EACH LIVING DAUGHTER BORN IN

2000 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE DAUGHTERS. BEGIN WITH THE YOUNGEST DAUGHTER. (IF THERE

ARE MORE THAN 3 DAUGHTERS, USE ADDITIONAL QUESTIONNAIRES).

(SPECIFY)

Was her genital area sewn

closed?

Who performed the

circumcision?

(SPECIFY)

(SPECIFY) (SPECIFY)

(SPECIFY)

W-3

A. Andro, M. LescLingAnd

278

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Document A (cont'd). Speciﬁc questionnaire on FGM

in the most recent Demographic and Health Surveys (DHS)

NO.

GC16 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

(2) NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

NO RELIGION . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

GC17 CONTINUED . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

STOPPED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

DEPENDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Do you think that female circumcision should be

continued, or should it be stopped?

QUESTIONS AND FILTERS CODING CATEGORIES SKIP

FEMALE GENITAL CUTTING/MUTILATION FOR WOMAN'S QUESTIONNAIRE (1)

Do you believe that female circumcision is required by

your religion?

W-4

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Table A.1. DHS(a) and MICS(b) surveys with a module on FGM(c)

and prevalence of FGM measured in each survey (%)

Country Number of surveys Survey year Type of survey % of women aged

15-49 with FGM

Benin 4

2014 MICS 9.2

2011-2012 DHS 7.3

2006 DHS 12.9

2001 DHS 16.8

Burkina Faso 4 2010 DHS 75.8

2006 MICS 72.5

2003 DHS 76.6

1998-1999 DHS 71.6

Cameroon 1 2004 DHS 1.4

Côte d’Ivoire 5

2011-2012 DHS 38.2

2006 MICS 36.0

2005 DHS 41.7

1998-1999 DHS 44.5

1994 DHS 42.7

Djibouti 1 2006 MICS 93.1

Egypt 6

2014 DHS 92.3

2008 DHS 95.5

2005 DHS 95.8

2003 DHS 97.0

2000 DHS 97.3

1995 DHS 97.0

Eritrea 22002 DHS 88.7

1995 DHS 94.5

Ethiopia 22005 DHS 74.3

2000 DHS 79.9

The Gambia 3

2013 DHS 74.9

2010 MICS 76.3

2005-2006 MICS 78.3

Ghana 3

2011 MICS 4.0

2006 MICS 3.8

2003 DHS 5.4

Guinea 3

2012 DHS 96.9

2005 DHS 95.0

1999 DHS 98.6

Guinea-Bissau 3

2014 MICS 44.9

2010 MICS 49.8

2006 MICS 44.5

Iraq 1 2011 MICS 8.1

Indonesia 1 2013 RISKESDAS 51.0

(d)

Kenya 3

2008-2009 DHS 27.1

2003 DHS 32.2

1998 DHS 37.6

Liberia 22013 DHS 49.8

2007 DHS 65.7

Mali 5

2012-2013 DHS 91.4

2010 MICS 89.0

2006 DHS 85.2

2001 DHS 91.4

1995-1996 DHS 93.7

A. Andro, M. LescLingAnd

280

Table A.1 (cont'd). DHS(a) and MICS(b) surveys with a module on FGM(c)

and prevalence of FGM measured in each survey (%)

Country Number of surveys Survey year Type of survey % of women aged

15-49 with FGM

Mauritania 3

2011 MICS 69.4

2007 MICS 72.2

2000-2001 DHS 71.3

Niger 3

2012 DHS 2.0

2006 DHS 2.2

1998 DHS 4.5

Nigeria 6

2013 DHS 24.8

2011 MICS 27.0

2008 DHS 29.6

2007 MICS 26.0

2003 DHS 19.0

1999 DHS 25.1

Uganda 22011 DHS 1.4

2006 DHS 0.6

Central African

Republic 4

2010 MICS 24.0

2006 MICS 25.7

2000 MICS 36.0

1994-1995 DHS 43.4

Tanzania 3

2010 DHS 14.6

2004-2005 DHS 14.6

1996 DHS 17.7

Senegal 3

2014 DHS 24.7

2010-2011 DHS 25.7

2005 DHS 28.2

Sierra Leone 4

2013 DHS 89.6

2010 MICS 88.0

2008 DHS 91.3

2005-2006 MICS 94.0

Somalia 1 2006 MICS 98.0

Sudan

(e) 3

2014 MICS 86.6

2000 MICS 90.0

1989-1990 DHS 89.2

Chad 3

2010 MICS 44.2

2004 DHS 44.9

2000 MICS 44.9

Togo 3

2013-2014 DHS 4.7

2010 MICS 4.0

2006 MICS 5.8

Yemen 22013 DHS 18.5

1997 DHS 22.6

TOTAL 89

(a) Demographic and Health Surveys.

(b) Multiple Indicator Cluster Surveys.

sentative national survey of 300,000 households carried out on the initiative of the Ministry of Health (RISKESDAS).

(d) Prevalence for girls aged 0-11 years only (UNICEF, 2015).

(e) In Sudan, data on FGM were collected only in the north of the country (UNICEF, 2013).

Female Genital mutilation. overview and Current KnowledGe

281

Table A.2. Year of adoption of anti-FGM laws in the 30 countries

with the highest prevalence of FGM

Country Year

Guinea 1965

Central African Republic 1966

Ghana 1994

Djibouti 1995

Burkina Faso 1996

Côte d’Ivoire 1998

Tanzanie 1998

Togo 1998

Nigeria 1999

Senegal 1999

Kenya 2001

Yemen 2001

Benin 2003

Niger 2003

Chad 2003

Ethiopia 2004

Mauritania 2005

Eritrea 2007

Egypt 2008

Sudan 2008

Uganda 2010

Guinea-Bissau 2011

Iraq 2011

Somalia 2012

Sierra Leone 2015

Cameroon (a)

Gambia (a)

Indonesia (a)

Liberia (a)

Mali (a)

(a) No law has been passed.

Source: UNICEF, 2013.

A. Andro, M. LescLingAnd

282

Table A.3. The ﬁve categories for describing readiness for change

Reported behaviour

(real or planned)

Reported opinion

Supports continuation

of the practice Undecided Supports abandonment

of the practice

Has or will have daughter (s) cut Willing

adherent Reluctant adherent

Not sure whether she will have

daughter (s) cut Contemplative

Will not have daughter (s) cut Reluctant abandoner Willing abandoner

Source: Shell-Duncan and Hernlund (2006).

Female Genital mutilation. overview and Current KnowledGe

283

Figure A.1. Method for estimating the number of women and girls with FGM

(aged 10 years and over) on the basis of data from the DHS/MICS surveys

For women aged

15-49 years

For women aged

50+ years

For girls aged

10-14 years

% of women with FGM

aged 15-49

by ﬁve-year age group

(DHS-MICS)

% of women with FGM

aged 45-49

(DHS-MICS)

% of women with FGM

aged 15-19

(DHS-MICS)

Total number of women

aged 15-49,

by ﬁve-year age group

(US Census Bureau’s

International Data Base)

Total number of women

aged 50+

(US Census Bureau’s

International Data Base)

Total number of girls

aged 10-14

(US Census Bureau

International Data Base)

Total number of women

with FGM aged 15-49

Total number of women

with FGM aged 50+

Total number of girls

with FGM aged 10-14

Total number of girls and women aged 10 years and above with FGM

in all countries of origin (101 milion)

Source: Yoder et al., 2013.

A. Andro, M. LescLingAnd

284

Figure A.2. Method for estimating the number of women with FGM

in countries of immigration using the indirect method

All women from one of the 30 countries

where FGM is practiced and living in the immigration country

Daughters of migrants

(or “second generation”)

women born in the country of immigration

and with “origins” in one of the 30 countries

where FGM is practiced

Group C

Women

with FGM

(C1)

Women

without

FGM

Women

with FGM

(B1)

Women

without

FGM

Women

with FGM

(A1)

Women

without

FGM

Estimation of the total number of women

with FGM living in the immigration country (= A1+B1+C1)

Migrant women:

women born in one of the 30 countries

where FGM is practiced

and living in the country of immigration

Migrant women

who arrived in

the country of immigration

during “at-risk” years

(before age 15)

Group B

Socialization hypothesis

(Coefﬁcient 3)

Migrant women

who arrived in

the country of immigration

after the “at-risk” years

(after age 15)

Group A

Adaptation or

disruption hypothesis

(Coefﬁcient 2)

Selection hypothesis

(Coefﬁcient 1)

INED

064A16

Source: Yoder et al., 2013.

Female Genital mutilation. overview and Current KnowledGe

285

REFERENCES

aBdelshahidA m y,caMpBellCatherine,

2015,“‘Shou ld Ic irc umcisemydaughte r?’

ExploringdiversityandambivalenceinEgyptianparents’socialrepresentationsof

femalecircumcision”,Journal of Community & Applied Social Psycholog y,25(1),pp.49- 65.

aBdulcadirJasmine,rodriguezMariaI.,saYLale,2015,“Asystematicreview

oftheevidenceonclitoralreconstructionafterfemale genitalmutilation/cutting”,

International Journal of Gynecology & Obstetrics,129(2),pp.93-97.

aBdulcadirJasmine,MargairazChristiane,BoulVainMichel,irionOl ivier,

2011,“Careofwomenwithfemalegenitalmutilation /cutting”,Swiss Medical Weekly,

140,pp.131-137.

BoYeJi

Biodun

p, i

JaiYa

unir

-d

een

A.,

2003,“Childhoodbenignsurgical

gynaecologicaldisordersinIlorin,Nigeria”,Tropical Jour nal of Obstetrics a nd Gynaecology,

20(1),pp.37-39.

aBusharafRogaia,

20 06,Female Circumcision: Multicultural Perspectives,Philadelphia,

UniversityofPennsylvaniaPress,296p.

hMadu

Fuambai, 2001,“Ritesandwrongs:Aninsider/outsiderreectsonpower

andexcision”,inShell-Duncan,Hernlund,Female Circumcision in Africa. Culture,

Controversy and Change,LynneRiennerPublishers,pp.283-312.

Kotionga

M.,t

raore

O.,l

aKoande

J.,K

one

B., 2001,“Séquellesgénitales

externesdel’excisionaucentrehospitaliernationalYalgadoOuedraogo:épidémiologie

ettraitement”,Gynecologie, obstetrique & fertilité,29(4),pp.295-300.

al-hussaini TarekK.,2003,“Femalegenitalcutting:Types,motivesandperineal

damageinlaboring Egyptianwomen”,Medical Principles and Practice,  12(2), 

pp.123-128.

alMrothLars,BedriHibba,el Mushar afSusan,sattiAlia,idrisTayseeret

al.,2005,“Urogenitalcomplicationsamonggirlswithgenitalmutilation:Ahospital-

basedstudyinKhartoum”,African Journal of Reproductive Health / La Revue africaine

de santé reproductive,9(2),pp.118-124.

lMroth

Lars,e

lMush araf

Susan,e

adi

Nagla,o

Beid

Abdelrahim,e

sheiKhMohamedA.A. etal.,2005,“Primaryinfertilityaftergenitalmutilationin

girlhoodinSudan:Acase-controlstudy”,The Lancet,366(9483),pp.385-391.

alsiBianiSharif aA.,rouziAbdulrahimA.,2010,“S exu alf uncti oninwome nw ith

femalegenitalmutilation”,Fertility and Sterility,93(3),pp.722-724.

ndro

Ar melle,l

esclingand

Marie,

2007,“Femalegenitalmutilation:thesituation

inAfricaandinFrance”,Population and Societies,438,4p.

androArmelle,lesclingandMarie,

2008,“Laperpétuationdelapratiquede

l’excisionencontextemigratoire”,Actes des colloques de l’Aidelf 2008,pp.613-616.

androArmelle,lesclingandMarie,pouretteDolorès,2009,“Voletqualitatif

duprojetExcisionethandicap(ExH):Commentorienterlapréventiondel’excision

chezlesllesetjeunesllesd’origineafricainevivanten France.Uneétudedes

déte rmin ant ssociauxetfami lia uxduphénomè ne”,R appor tderech erchepourl’ACSE,

Paris,INED-Paris1.

A. Andro, M. LescLingAnd

286



ndro

Armelle,l

esclingand

Marie,p

ourette

Dolorès,

2010,“Excisionet

cheminementverslaréparation:unepriseenchargechirurgicaleentreexpérience

personnelleetdynamiquesfamiliales”,Sociétés contemporaines,77(1),pp.139-161.

androArmelle,caMBoisEmmanuelle,lesclingandMarie,2014,“Long-term

consequencesoffemalegenitalmutilationinaEuropeancontext:Selfperceivedhealth

ofFGMwomencomparedtonon-FGMwomen”,Social Science & Medicine,106(C),

pp.177-184.

ndro

Ar melle,l

esclingand

Marie,c

aMBois

Em manuel le,c

irBeau

Christelle,

2009,“VoletquantitatifduprojetExcisionethandicap(ExH):mesuredeslésionset

traumatismesetévaluationdesbesoinsenchirurgieréparatrice”,Rapportderecherche

pourlaDGS,Paris,INED-Paris1.

ntonetti

NdiayeE.,f

all

S.,B

eltran

L.,

2015,“Intérêtdelapriseencharge

pluridisciplinairedesfemmesexcisées”,Journal de gynécologie, obstétrique et biologie

de la reproduction,44(9),pp.862-869.

asKeWIan,2005,“Methodologicalissuesinmeasuringtheimpactofinterventions

againstfemalegenitalcutting”,Culture, Health & Sexuality,7(5),pp.463-477.

arth

Fred r ik,

1969,Ethnic Groups and Boundaries: The Social Organization of Culture

Difference,Little,BrownseriesinAnthropology,153p.

ehrendt

Al ice,

2011,“ListeningtoAfricanvoices”,Female Genital Mutilation/Cutting

among Immigrants in Hamburg: Knowledge, Attitudes and Practice, PlanInternational

Deutschlande.V.,Hamburg.

BellKirsten,2005,“Genitalcuttingandwesterndiscoursesonsexuality”,Medical

Anthropology Quarterly,19(2),pp.125-148.

Bellas caBaneChristine,2008,La coupure: l’excision ou les identités douloureuses,

Paris,LaDispute,245p.

BenelliNatalie,delphYChristine,falquetJules,haMelChristelle,hertz

Ellen,rouxPat rici a,

2006,“Lesapprochespostcoloniales:apportspourunféminisme

ant i r a c i ste”, Nouvelles questions féministes,25(3),pp.4-12.

erg

RigmorC,d

enison

Eva,2012,“Doe sfema lege nit a lmut ilat io n /c ut ting(FG M /C)

affectwomen’ssexualfunctioning?Asystematicreviewofthesexualconsequences

ofFGM/C”,Sexuality Research and Social Policy,9(1),pp.41-56.

BergRigmorC .,denisonEva,

2013,“Atradit ionintra nsition:Fact orspe r pet uat ing

andhinderingthecontinuanceoffemalegenitalmutilation/cutting(FGM/C)summarized

inasystematicreview”,Health Care for Women International,34(10),pp.837-859.

BergRigmorC.,underlandVigdis,2013,“Theobstetricconsequencesoffemale

genitalmutilation/cutting:Asystematicreviewandmeta-analysis”,Obstetrics and

Gynecology International,pp.496-564.

erg

RigmorC.,u

nderland

Vigd is,o

dgaard

-J

ensen

Jan,f

retheiM

At le,V

ist

GunnE.,

2014,“Effectsoffemalegenitalcuttingonphysicalhealthoutcomes:A

systematicreviewandmeta-analysis”,British Medical Journal,4(11),pp.1-12.

BoddYJanice,

1991,“ Bod yPol it ics:Cont inuingth ea nti cir cumcis io nc r usa de”,Medical

Anthropology Quarterly,5(1),pp.15-17.

BoddYJanice,2007,“Gendercrusades:Thefemalecircumcisioncontroversyincultural

perspective”,inTranscu ltural bodie s,NewBrun swick, Ne wJers eyandLondon,Rutger s

UniversityPress,pp.46-66.

BoniTanella,2009,“Corpsblessés,corpsretrouvés?”,Diogène,225(1),pp.15-32.

BourdieuPierre,1982,“Lesritescom meactesd’i nstitution”,Actes de la recherche en

sciences sociales,43(1),pp.58-63.

oYle

El izab eth ,

20 05,Fem ale Genital Cutting : Cult ural Conﬂict in the Global Community,

BaltimoreMd,London,JohnsHopkinsUniversityPress,188p.

Female Genital mutilation. overview and Current KnowledGe

287

BoYleElizabethHeger,McMorrisBarbaraJ.,goMezMay ra,

2002,“Localconformity

tointernationalnorms thecaseoffemalegenitalcutting”,International Sociology,

17(1),pp.5-33.

BrewerDevonD.,PotteratJohnJ.,RobertsJohnM.,BrodyStuart,

2007,“Male

andfemalecircumcisionassociatedwithprevalentHIVinfectioninvirgins and

adolescentsinKenya,Lesotho,andTanzania”,Annals of Epidemiology,17(3),pp.217.

e1-217.e12.

BudiharsanaMeiwita,aMaliahLila,utoMoBudi,2003,“Femalecircumcision

inIndonesia. Extent,implicationsandpossibleinterventionstoupholdwomen’s

healthrights”,Jakarta,PopulationCouncilandUSAID,56p.

carillonSéverine,petitVéronique,2009,“Lapratiquedesmutilationsgénitales

fémininesàDjibouti:une“affairedefemmes”entrelesmainsdeshommes”,Autrepart,

52(4),pp.13-29.

arr

Dara,

19 9 7, Female genital cutting: Findings from the Demographic and Health

Surveys Program,Calverton,Maryland,MacroInternationalInc.,96p.

artrY

M.,

1968,“Lacalebassedel’excisionenpaysgourmantché”,Journal de la

société des Africanistes,38(2),pp.189-226.

atania

Lucrezia,a

Bdulcadir

Omar,p

uppo

Vincenzo,V

erde

JoleBaldaro,

Bdulcadir

Jasmine,a

Bdulcadir

Dalmar,

20 07,“Pl easureandorga smi nwomen

withfemalegenitalmutilation /cutting(FGM/C)”,The Journal of Sexual Medicine, 4(6),

pp.1666-1678.

chéronG.,

1933,“Lacirconcisionetl’excisionchezlesMalinké”,Journal de la société

des Africanistes,3(2),pp.297-303.

coeneGily,

2007,“Êtreféministe,cen’estpasexclure!”,Revue européenne de migrat ions

internationales,23(2),pp.79-105.

colleYnJean-Paul,1975,“Surlecheminduvillage:l’initiationauKoroMinyanka”,

Journal de la société des Africanistes,45(1),pp.115-125.

cooKRebeccaJ.,dicKensBernardM.,2010,“Specialcommentaryontheissue

ofreinfibulation”,International Journal of Gynecology & Obstetrics,109(2),

pp.97-99.

couchardFrançoise,2003,L’excision,Paris,PressesuniversitairesdeFrance,Que

sais-je?,128p.

cutnerLawrence,1985,“Femalegenitalmutilation”,Obstetrical & Gynecological

Survey,40(7),pp.437-443.

dareFO,oBoroVO,fadioraSO,orJiEO,sule-oduAO,olaBodeTO,2004,

“Femalegenitalmutilation:Ananalysisof522casesinSouth-WesternNigeria”,Journal

of Obstetrics & Gynecology,24(3),pp.281-283.

dieleManMyri am,2010,“ExcisionetmigrationenBelgiquefrancophone”,Rapport

derecherchedel’Observatoiredusidaetdes sexualitéspourleGAMSBelgique,

Bruxelles,GAMSBelgique.

diopNafissatouJ.,congoZakari,ouédraogoAïna,saWadogoAlphonsine,

saloucouLydia,taMiniIda,2008,“Analysisoftheevolutionofthepracticeof

femalegenitalmutilation/cuttinginBurkinaFaso”,PopulationCouncil,Frontiersin

ReproductiveHealth,USAID,56p.

dorlinElsa(ed.),200 9, Sexe, race, classe: pour une épistémologie de la domination,

Paris,PressesuniversitairesdeFrance,ActuelMarxconfrontation,320p.

roz

Yvan,

20 00,“Circo nc i sionfémini neetmasc uli neenp ayskik uyu:rite d’ instit ution ,

divisionsocialeetdroitsdel’Homme[Maleandfemalecircumcisionamongthe

Kikuyu:Ariteofinstitution,socialdivisionandhumanrights]”,Cahiers d’études

africaines,158,pp.215-240.

A. Andro, M. LescLingAnd

288

duBourgDominique,richardFabienne,leYeEls,ndaMeSamuel,roMMens

Tine,M

aes

Sophie,

2011,“Estimatingthe numberofwomenwithfemalegenital

mutilationinBelgium”,The European Journal of Contraception & Reproductive Health

Care,16(4),pp.248-257.

Kenze

S.O.,e

zegWui

H.U.,a

diri

C.O.,

20 07,“Gen ita llesionscomp lic at i ngfem ale

genitalcuttingininfancy:Ahospital-basedstudy insouth-eastNigeria”,Annals of

Tropical Paediatrics: International Child Health,27(4),pp.285-290.

ElDareerA.,

1983,“ComplicationsoffemalecircumcisionintheSudan”,Tropic al

Doctor,13(3),pp.131-133.

elMusharafS.,elKhidirI.,hoffM annS.,alMrothL.,2006a,“Acase–control

studyontheassociationbetweenfemalegenitalmutilationandsexuallytransmitted

infectionsinSudan”,BJOG: An International Journal of Obstetrics & Gynaecology,

113(4),pp.469-474.

elMusharafS.,elh adiN.,alMrothL.,2006b,“Reliabilityofselfreportedform

offemalegenitalmutilationandWHOclassication:crosssectionalstudy”,British

Medical Journal,333(7559),5p.

rlich

Michel,

1986,La femme blessée. Essai sur les mutilations sexuelles féminines,

Paris,L’Harmattan,326p.

ssén

Birgitta,s

JöBerg

Nils-Otto,g

udMundsson

Saemundur,ö

stergren

P.- O.,

indqVist

PelleG.,

20 05,“Noass oci ationbetwe enfemaleci rcumc isionandprolonge d

labour:AcasecontrolstudyofimmigrantwomengivingbirthinSweden”,European

Journal of Obstetrics & Gynecology and Reproductive Biology,121(2),pp.182-185.

european institute for gender equalitY,2013,Female Genital Mutilation in the

European Union and Croatia,Luxembourg,EuropeanInstituteforGenderEquality,

PublicationOfceoftheEuropeanUnionReport,115p.

exterK ate Marja,2013,“FemalegenitalmutilationintheNetherlands.Prevalence,

incidenceanddeterminants”,Utrecht,TheNetherlands,Pharos,CentreofExpertise

onHealthforMigrantsandRefugees.

fainzangSylvie,

1985,“Circoncision,excisionetrapportsdedomination”,Anthropologie

et sociétés,9(1),pp.117-127.

farinaPatrizia,ortensiLiviaElisa,2014a,“Mothertodaughtertransmissionof

femalegenitalcuttinginEgypt,BurkinaFasoandSenegal”,African Population Studies,

28(2s),pp.1119-1131.

farinaPatrizia,ortensiLiviaElis a,2014b,“Themot hertodaughtert rans mis sion

offemalegenitalcuttinginemigrationasevidencedbyItaliansurveydata”,Genus,

70(2-3),pp.111-137.

illo

G.F.,l

eone

T.,

2007,“Femalegenitalcuttingreproductivetractinfectionsand

perinataloutcomeinBurkinaFaso”,presentedatthePAAconference.

foldèsPierre,BuissonOdi le,2009,“Theclitoralcomplex:Adynamicsonographic

st u d y”,The Journal of Sexual Medicine,6(5),pp.1223-1231.

foldèsPierre,louis-sYlVestre C.,2006,“Résultatsdelaréparationchirurgicale

duclitorisaprèsmutilationsexuelle:453cas”,Gynécologie Obstétrique & Fertilité,

34(12),pp.1137-1141.

oldès

Pierre,c

uzin

Béatrice,a

ndro

Armelle,

2012,“Reconstructivesurgery

afterfemalegenitalmutilation:Aprospectivecohortstudy”,The Lancet,380(9837),

pp.134-141.

agnon

John,B

ourcier

Marie-Hélène,g

iaMi

Al ain,200 8,Les scripts de la sexu alité:

essais sur les origines culturelles du désir,Paris,Payot,202p.

iaMi

Al ain,2007,“Fonctionsexuellemasculineetsexualitéféminine”,Communications,

81(1),pp.135-151.

Female Genital mutilation. overview and Current KnowledGe

289

griauleMarcel,1948,Die u d ’ea u, Entretiens avec Ogotemmêli,Paris,Éditionsdu

Chêne,224p.

ruenBauM

Ellen,

2001, The Female Circumcision Controversy: An Anthropological

Perspective,Philadelphia,UniversityofPennsylvaniaPress,242p.

aMBurger

C.,s

turup

G.K., d

ahl

-i

Versen

E.,

1953,“Transvestism.Hormonal,

psychiatric,andsurgicaltreatement”,The Journal of the American Medical Association,

152(5),pp.391-396.

aYford

Sa rahR,t

rinitapoli

Je n ny,

2011,“Religiousdifferencesinfemalegenital

cutting:AcasestudyfromBurkinaFaso”,Journal for the Scientiﬁc Study of Religion,

50(2),pp.252-271.

hernlundYlva,2001,“Cuttingwithoutritualandritualwithoutcutting:Female

“circumcision”and there-ritualizationofinitiationintheGambia.”,inBoulder,

Colo.,Shell-DuncanandHernlund,Female “Circumcision” in Afr ica. Culture, Controversy

and Change, Rienner Publishers, Directions in Applied Anthropology,

pp.235-252.

hernlundYlva,shell-duncanBettina,2 0 0 7,Transcultural Bodies Female Genital

Cutting in Global Context,NewBrunswick,N.J.,RutgersUniversityPress,432p.

osKen

FranP.,1978,“Theepidemiologyoffemalegenitalmutilations”,Tro p ical

Doctor,8,pp.150-156.

hosKenFranP., 1979,The Hosken Report: Genital and Sexual Mutilation of Females,

Lexington,MA,Women’sInternationalNetworkNews.

hosKenFranP.,1982,The Hosken Report: Genital and Sexual Mutilation of Females,

3rdrev.ed,Lexington,Mass.,Women’sInternationalNetworkNews,327p.

osKen

FranP.,

1995,Stop Female Genital Mutilation: Women Speak, Facts and Actions,

Lexington,MA,Women’sInternationalNetworkNews,128p.

Ab.R ahman,s

huiB

Rashidah,o

thMan

M.Shukri ,

1999,“Thepracticeoffemale

circumcisionamongMuslimsinKelantan,Malaysia”,Reproductive Health Matters,

7(13),pp.137-144.

JacKsonElizabet hF.,aKWeongoPatr icia,saKeahEvely n,hodgsonAbraham,

asuruRofina,phillipsJamesF.,2003,“Inconsistentreportingoffemalegenital

cuttingstatusinnorthernGhana:Explanatoryfactorsandanalyticalconsequences”,

Studies in Family Planning,34(3),pp.200-210.

JohnsdotterSara,

2007,“Persistenceoftraditionorreassessmentofculturalpractices

inexile.DiscoursesonfemalecircumcisionamongandaboutSwedishSomalis”,in

HernlundYlva,Shell-DuncanBettina, Transcultural Bodies. Female Genital Cutting in

Global Context,NewBrunswick,RutgersUniversityPress,pp.107-134.

JohnsdotterSara,essénBirgitta,

2010,“Genitalsandethnicity:Thepoliticsof

genitalmodications”,Reproductive Health Matters,18(35),pp.29-37.

ohnsdotter

Sa ra,M

oussa

Kontie,c

arlBoM

Aje,a

regai

Rishan ,e

ssén

Birgitta,

2009,“’Nevermydaughters’:Aqualitativestudyregardingattitudechangetoward

femalegenitalcuttingamongEthiopianandEritreanfamiliesinSweden”,Health Care

for Women International,30(1-2),pp.114-133.

JohnsonMichelle,

20 01, “Beco min gaMuslim,b ecomingaper son:Fem ale“circum cision”,

religiousidentity,andpersonhoodinGuinea-Bissau”,inShell-DuncanBettina,Hernlund

Ylva,Female “Circumcision” in Afr ica. Culture, Controversy and Change,Ly n neR ie nne r

Publishers,DirectionsinAppliedAnthropology,pp.215-233.

JohnsonMichelle,2007,“MakingMandingaorMakungMuslums.Debatingfemale

ci rcu mci sion,et hni cit y,a ndIsl ami nGuinea-Bi s sauan dPor tugal”,inH ern lundY lva,

Shell-DuncanBettina,Transcultural Bodies. Female Genital Cutting in Global Context,

RutgersUniversityPress,NewBrunswick,NewJerseyandLondon,pp.202-223.

A. Andro, M. LescLingAnd

290

ones

WandaK.,s

Mith

Jack,K

ieKe

Burney,W

ilcox

Lynne,

1997,“Fema legen it a l

mutilation/female circumcision.Whoisatriskin theU.S.”,Public Health Reports,

112(5),pp.368-377.

KaplanAdriana,hechaVarríaSuiberto,MartínMiguel,BonhoureIsabelle,

2011,“Healthconsequencesoffemalegenitalmutilation/cuttingintheGambia,

evidenceintoaction”,Reproductive Health,8(26),pp.1-6.

louMan

Elise,M

anongi

Rachel,K

lepp

Knut-Inge,

2005,“Self-reported and

observedfemalegenitalcuttinginruralTanzania:Associateddemographicfactors,

HIVandsexuallytransmittedinfections”,Tropical medicine & International Health,

10(1),pp.105-115.

KnightMary,2001,“Curingcutorritualmutilation?Someremarksonthepractice

offemaleandmalecircumcisioninGraeco-RomanEgypt”,Isis,92(2),pp.317-338.

arBer a

MariaCaterina,2009,Multicentered Feminism: Revisiting the “Female

Genital Mutilation” Discourse,Palermo,Compostampa,336p.

laqueurThom asWa lter,2005,Le sexe en solitaire: contribution à l’histoire culturelle

de la sexualité,Paris,Gallimard,512p.

arsen

Ulla, o

Konofua

FridayE,2002,“Femalecircumcisionandobstetric

complications”,International Journal of Gynecolog y & Obstetrics,77(3),pp.255-265.

PeterA.,h

ouK

ChristopherP.,a

hMed

S.Faisal,h

ughes

IeuanA.,

2006,

“Consensusstatementonmanagementofintersexdisorders”,InternationalConsensus

ConferenceonIntersex,Pediatrics,118(2),pp.e488-e500.

eonard

Lori,

1996,“Fema lecircum cis ioninSout her nCh ad:Or igin s,mean ing,a nd

currentpractice”,Social Science & Medicine,43(2),pp.255-263.

eWnes

Alexia,B

arr aud

MarietteMosette,u

nicef

,i

nnocenti

esearch

centre,2005,“Changeruneconventionsocialenéfaste:lapratiquedel’excision/

mutilationgénitaleféminine”,Florence,Italy,UNICEFOfceofResearch-Innocenti,

54p

eYe

El s,M

ergaert

Lut,a

rnaut

Catari n a,o’B

rien

Gree nSioban,

2014,“Towards

abetterestimationofprevalenceoffemalegenitalmutilationintheEuropeanUnion:

InterpretingexistingevidenceinallEUMemberStates”,Genus,70(1),pp.99-121.

eYe

El s,d

eBlonde

Jessi ka,g

arcía

-a

ñón

José,J

ohnsdotter

Sa ra,K

Wateng

KluVitseAdwoaetal.,2007,“Ananalysisoftheimplementationoflawswith

regardtofemalegenitalmutilationinEurope”,Crime, Law and Social Change,47(1),

pp.1-31.

löWYIlana,2003,“Intersexeettranssexualités:lestechnologiesdelamédecineet

laséparationdusexebiologiquedusexesocial”,Cahiers du genre,34(1),pp.81-104.

MacfarlaneAli son,dorKenooEf ua,2014,“Femalegenital mutil ationinEng lan d

andWales:Updatedstatisticalestimatesofthenumbersofaffectedwomenlivingin

EnglandandWalesandgirlsatrisk.Interimreportonprovisionalestimates”,City

UniversityLondon,EqualityNow.

MacKieGerry,1996,“Endingfootbindingandinbulation:Aconventionaccount”,

American Sociological Review,61(6),pp.999-1017.

acKie

Ger r y,

20 03,“Femalegen italcutti ng:Ah armlesspr act ice?”,Medical Anthropology

Quarterly,17(2),pp.135-158.

MacKieGe r r y,leJeuneJohn,2009,“Socialdynamicsofabandonmentofharmful

practices:Anewlookatthetheory”,SpecialSeriesonSocialNormsandHarmful

Practices,Innocentiworkingpaper,6.

arpsat

Maryse,r

azafindr atsiMa

Nicolas,2013,“Lareprésentativitéetles

populationsdifcilesàjoindre:lecasdessans-domicile”,inSelzMarion,La re présent ativit é

en statistique,Paris,INED,Méthodesetsavoirs,8,pp.67-86.

Female Genital mutilation. overview and Current KnowledGe

291

MasseYDouglasS.,1998,Worlds in Motion: Understanding International Migration at

the End of the Millenium,IUSSP(ed.),Oxford;NewYork,NewYork,ClarendonPre ss/

OxfordUniversityPress,InternationalStudiesinDemography,362p.

MBoWPenda,

1999,“Pénaliserunfaitculturel:quellesolutionàl’excision?”,Présence

africaine,160(2),pp.67-77.

ercKel Bagh

H.-M.,n

icolas

M.-N., p

iKettY

 M .- P.,  B

enifl a

J.-L.-B.,

2015,

“Évaluationd’unepriseenchargemultidisciplinairechez169patientesexcisées

demandeusesd’unechirurgieréparatrice”,Gynécologie obstétrique & fertilité,43(10),

pp.633-639.

ModreKSepideh,liuJenny,2013,“Explorationofpathwaysrelatedtothedecline

infemalecircumcisioninEgypt”,BMC Public Health,13(1),p.921.

odreK

Sepideh,s

ieVerding

Maia,

2015,“Mother,daughter,doctor:Medical

professionalsandmothers’decision-makingaboutfemalegenitalmutilation/cutting

inEgypt”,PAASanDiego.

MoMohComfort,ladhaniShamez,lochrieDeniseP.,rYMerJanice,

2001,

“Femalegenitalmutilation:AnalysisofthersttwelvemonthsofasoutheastLondon

specialistclinic”,British Journal of Obstetrics and Gynaecology,108(2),pp.186-191.

orison

L.,s

cherf

C.,e

Kpo

G.,p

aine

K.,W

est

B.etal.,

2001,“The long-term

reproductivehealthconsequencesoffemalegenitalcuttinginruralGambia:Acommunity-

basedsurvey”,Tropical Medicine & International Health, 6(8),pp.643-653.

MullerJean-Claude,1993,“Lesdeuxfoiscirconcisetlespresqueexcisées.Lecasdes

Dììdel’Adamaoua(NordCameroun)”,Cahiers d’études africaines,33(4),pp.531-544.

ndiaYePapa,diongueMayassine,faYeAdama,ouedraogoDrissa,diaAnt a

Tal,2010,“Mutilationgénitaleféminineetcomplicationsdel’accouchementdansla

provincedeGourma(BurkinaFaso)”,Santé publique,22(5),pp.563-570.

nJueCarolyne,asKeWIan,2004,“Medicalizationoffemalegenitalcuttingamong

theAbagusiiinNyanzaProvince,Kenya”,WashingtonDC,PopulationCouncil,

FrontiersinReproductiveHealth,30p.

nourNawalM.,MichelsKarinB.,BrYantAnnE.,2006,“Debulationtotreat

femalegenitalcutting:Effectonsymptomsandsexualfunction”,Obstetrics & Gynecology,

108(1),pp.55-60.

oBerMeYerCarlaMakhlouf,1999,“Fem a le ge nit als urger ies:Theknown,theun k now n,

andtheunknowable”,Medical Anthropology Quarterly,13(1),pp.79-106.

BerMeYer

Ca rlaMak h louf,

2003,“Thehealthconsequencesoffemalecircumcision:

Science,advocacy,andstandardsofevidence”,Medical Anthropology Quarterly,17(3),

pp.394-412.

oBerMeYerCarlaMakhlouf,2005,“Theconsequencesoffemalecircumcisionfor

healthandsexuality:Anupdateontheevidence”,Culture, Health & Sexuality,7(5),

pp.443-461.

oKonofuaF.E,lar senU.,oronsaYeF.,snoWR.C.,slangerT.E .,2002,“The

associationbetweenfemalegenitalcuttingandcorrelatesofsexualandgynaecological

morbidity inEdoState,Nigeria”,BJOG: An International Journal of Obstetrics &

Gynaecology,109(10),pp.1089-1096.

rtensi

LiviaElisa,f

arina

Patri z ia,M

enonna

Alessio,

2015,“Improvingestimates

oftheprevalenceoffemale genitalmutilation/cuttingamongmigrants inWestern

countries”,Demographic Research,32(18),pp.543-562.

ruBuloYe

I.O.,c

aldWell

P.,c

aldWell

J.C.,20 01,“Fema lecir cumcis iona mong

theYorubaofSouthwestNigeria:Thebeginningofchange”,inShell-DuncanBettina,

HernlundYlva(eds.), Female “Circumcision” in Africa. Culture, Controversy and Change,

LynneRiennerPublishers,pp.73-94.

A. Andro, M. LescLingAnd

292

ouedraogoC.M.R.,MadzouS.,touréB.,ouédraogo A.,ouédraogoS.,

lanKoandéJ.,2013,“Pratiquedelachirurgieplastiquereconstructriceduclitoris

aprèsmutilationsgénitalesauBurkinaFaso.Àproposde94cas”,Annales de chirurgie

plastique esthétique,58(3),pp.208-215.

population reference Bureau(PRB),2013,“Womenandgirlsatriskoffemale

genitalmutilation/cuttingintheUnitedStates”.

prochasK aJ.O.,VelicerW.F.,rossiJ.S.,goldsteinM.G.,MarcusB.H.et

al., 1994,“Stagesofch angeanddecis iona lbal ancefor12problembehaviors”,Health

Psychology,13(1),pp.39-46.

rahManAnika,touBiaNah id,CenterforReproducti veLaw&Pol icy,RAIN BO

(Organization)(eds.),2000,Female Genital Mutilation: A Guide to Laws and Policies

Worldwide,London/NewYork,ZedBooks,249p.

asheed

Sa lahM.,a

-e

llah

Ah medH.,Y

ousef

FouadM.,

2011,“Femalegen ita l

mutilationinUpperEgyptinthenewmillennium”,International Jour nal of Gynecology

and Obstetrics,114(1),pp.47-50.

rashidA.,PatilS.,ValiMalarA.,2009,“Thepracticeoffemalegenitalmutilation

amongtheruralMalaysinNorthMalaysia”,The Internet Jour nal of Third World Medicine,

9(1),pp.1-8.

serourGamal,2010,“Theissueofreinbulation”,International Journal of Gynecology

& Obstetrics,109(2),pp.93-96.

serourGamal,2013,“Medicalizationoffemalegenitalmutilation/cutting”,Female

Genital Cutting/Mutilation in Africa,19(3),pp.145-149.

shell-duncan Bettina,2001,“Themedicalizationoffemale“circumcision”:Harm

reductionorpromotionofadangerouspractice?”,Social Science & Medicine,52(7),

pp.1013-1028.

hell

-d

uncan

Betti n a,2008,“Fromhealthtohumanrights:Femalegenitalcutting

andthepoliticsofintervention”,American Anthropologist,110(2),pp.225-236.

shell-duncanBettina,hernlu ndYlva(eds.),

2001, Female “Circumcision” in

Africa: Culture, Controversy, and Change,LynneRiennerPublishers,349p.

shell-duncanBettina,hernlundYlva,2006,“Arethere‘stagesofchange’inthe

practiceoffemalegenitalcutting?QualitativeresearchndingsfromSenegalandthe

Gamb i a””, African Journal of Reproductive Health,10(2),pp.57-71.

hell

-d

uncan

Bettina,o

Biero

WalterObungu,M

uruli

LeunitaAuko,

2001,

“Womenwithoutchoices:Thedebateovermedicalizationoffemalegenitalcutting

anditsimpactonaNorthernKenyancommunity”,inShell-DuncanBettina,Hernlund

Ylva(eds.), Female “Circumcision” in Africa. Culture, Controversy and Change,Lynne

RiennerPublishers,pp.109-128.

hell

-d

uncan

Betti na,W

ander

Katherine,h

ernlund

Ylva,M

oreau

Am adou,

2013,“Legislatingchange?Responsestocriminalizingfemalegenitalcuttingin

Sen e gal”, Law & Society Review,47(4),pp.803-835.

iMon

Patrick,

2012,“CollectingethnicstatisticsinEurope:Areview”,Ethnic and

Racial Studies,35(8),pp.1366-1391.

indzingre

Nicole,

1977,“Leplusetlemoins:àproposdel’excision”,Cahiers d’études

africaines,17(65),pp.65-75.

indzingre

Nicole,1979,“Unexcèspardéfaut:excisionetreprésentationsdela

fé m i n ité”, L’Homme,19(3),pp.171-187.

noW

R.C.,s

langer

T.E.,o

Konofua

F.E.,o

ronsaYe

F., W

acKer

J.,

2002,

“Femalegenitalcuttinginsouthernurban andperi-urbanNigeria:Self-reported

validity,socialdeterminantsandseculardecline”,Tropical Medicine and International

Health,7(1),pp.91-100.

Female Genital mutilation. overview and Current KnowledGe

293

Fatou,1997,“Mutilationssexuelles fémininesetdroitshumainsen Afrique”,

Clio,6,5p.

teMinMyriam,MontgoMerYMarkR.,engeBretsenSarah,BarKerKathryn

M.,

2013,“Girlonthemove:Adolescentgirls&migrationinthedevelopingworld”,

Girls Count Report,NewYork,PopulationCouncil,136p.

thaBetS.M.A.,thaBetAhmedS.M.A.,

2003,“Defectivesexualityandfemale

circumcision:Thecauseandthepossiblemanagement”,Journal of Obstetrics and

Gynaecology Research,29(1),pp.12-19.

thiaMAwa,1978,La parole aux négresses. Préface de Benoîte Groult,Paris,Denoël/

Gonthier,Femme,189p.

ouBia

N.,1993,Female Genital Mutilation: a Call for Global Action,NewYor k,Women, 

Ink,48p.

ouBia

N.F.,s

harief

E.H.,

2003,“Femalegenitalmutilation:Havewemadeprogress?”,

International Journal of Gynecology & Obstetrics,82(3),pp.251-261.

UNF PA,2011,“ProjectEmbera-Wera.Anexperienceofculturalchangetoeradicate

femalegenitalmutilationinColombia-LatinAmerica”,UNFPA,21p.

UNF PA,

2014,“Implementationoftheinternationalandregionalhumanrightsframework

fortheeliminationoffemalegenitalmutilation”,UNFPA,88p.

UNFPA,UNICEF,2009,“Femalegenitalmutilation/cutting:Acceleratingchange”,

30p.

UNFPA,UNICEF,

2014,“UNFPA/UNICEFjointprogrammeonfemalegenitalmutilation/

cutting-acceleratingchange”,UNFPA-UNICEF.

UN FPA,UNHCR ,UN IC EF,UNIFEM,WHO,

2010,“Globalstrategytostophealth-

careprovidersfromperformingfemalegenitalmutilation”,17p.

UN HCR,

20 09,“Guid a nc enoteonrefugeecl a ims rel at i ngtofem alegenit almutilation”,

Geneva,UNHCR,15p.

UN HC R,

2013,“Toomuchpain.Femalegenitalmutilation&asylumintheEuropean

Union.Astatisticaloverview”,UNHCR,36p.

UNICEF,

2005,“Femalegenitalmutilation/cutting: astatisticalexploration2005”,

53p.

UNICEF,2010,“LegislativereformtosupporttheabandonmentofFGMC”,61p.

UNIC E F,

2013,“Femalegenitalmutilation/cutting:Astatisticaloverviewandexploration

ofthedynamicsofchange”,194p.

UNICEF,

2015,“Indonesia.Statisticalproleonfemalegenitalmutilation/cutting”,

DivisionofData,ResearchandPolicy,NewYork,4p.

UNIC E F,2016,“Femalegenitalmutilation /cutting:Aglobalconcern”,NewYork,2p.

UNICEF,i

nnocenti

esearch

entre

,2010,“Thedynamicsofsocialchange:

Towardstheabandonmentoffemalegenitalmutilation/cuttinginveAfricancountries”,

Florence,Italy,68p.

united nations, 1959,Yearbook of the United Nations.

ennep

Arnold,

1909,Les rites de passage: étude systématique des rites, [New

edition2011],Paris,Picard,316p.

VillaniMichela,2009,“Dela“maturité”delafemmeàlachirurgie:lesconditions

delaréparationduclitoris”,Sexologies,18(4),pp.259-261.

VillaniMichela,androArmelle,2010,“Réparationduclitorisetreconstruction

dela sexualité chezlesfemmesexcisées:la placeduplaisir”,Nouvelles questions

féministes,29(3),pp.23-43.

VissandJéeBilkis,denettoShereen,MigliardiPaula,proctorJodi,

2014,

“Femalegenitalcutting(FGC)andtheethicsofcare:Communityengagementand

A. Andro, M. LescLingAnd

294

culturalsensitivityattheinterfaceofmigrationexperiences”,BMC Internat ional Health

and Human Rights,14(13),10p.

loeBerghs

Erick,

Van

der

WaaK

Anke,K

nipsche er

Jeroen,

Van

den

MuiJsenBerghMaria,

2012,“Copingandchronicpsychosocialconsequencesof

female genital mutilation in t he Netherlands”, Ethnicity & Health, 17(6),

pp.677-695.

WadeL.,2012,“Learningfrom“femalegenitalmutilation”:Lessonsfrom30yearsof

academicdiscourse”,Ethnicities,12(1),pp.26-49.

WADI, 2010,“FemalegenitalmutilationinIraqi-Kurdistan.Anempiricalstudyby

WADI”,Frankfurtam Main,AssociationforCrisisAssistance andDevelopment

Co-operation.

Watson MaryAnn,2005,“FemalecircumcisionfromAfricatotheAmericas:Slavery

tothepresent”,The Social Science Journal,42(3),pp.421-437.

WHO,1959,“Resolution”,5p.

WHO,

1979,“Seminarontraditionalpracticesaffectingthehealthofwomenand

children”,Khartoum.

WHO,1996,“Femalegenitalmutilation:reportofaWHOtechnicalworkinggroup”.

WHO,1997,“Femalegenitalmutilation.AjointWHO/UNICEF/UNFPAstatement”.

WHO,2000,“Asystematicreviewofthehealthcomplicationsoffemalegenitalmutilation

includingsequelaeinchildbirth”,181p.

WHO,2008,“Eliminatingfemalegenitalmutilation,aninteragencystatement”,47p.

WHO,

2011,“EstimatingtheobstetriccostsoffemalegenitalmutilationinsixAfrican

countries”,2p.

Who s

tudY

roup

eMale

enital

utilation

and

Bstetric

utcoMe

,

2006,“Femalegenitalmutilationandobstetricoutcome:WHOcollaborativeprospective

studyinsixAfricancountries”,The Lancet,367(9525),pp.1835-1841.

uest

s., r

aio

l., W

YssMueller

d., M

ueller

M. d., s

tadlMaYr

W.etal.,

20 09,

“EffectsoffemalegenitalmutilationonbirthoutcomesinSwitzerland”,BJOG : An

International Journal of Obstetrics and Gynaecology,116(9),pp.1204-1209.

YoderP.Stanley,aBderrahiMNoureddine,zhuzhuniArlinda,2004,“Female

genitalcuttingintheDemographicandHealthSurveys:Acriticalandcomparative

analysis”,DHS Comparative Reports,7,Calverton,Maryland,MacroInternationalInc.,

79p.

YoderP.Stanley,KhanShane,2008,“NumbersofwomencircumcisedinAfrica:

Theproductionofatotal”,Demographic and Health Research,Calverton,Maryland,

23p.

oder

P.St anley,W

ang

Shanxi ao,

2013,“Fem alegenitalcuttin g:Th ei nterpret ation 

ofrecentDHSdata”,DHS Comparative Reports,33,Calverton,Maryland,USA,ICF

International,73p.

YoderP.Stanley,WangShanxiao,JohansenElise,

2013,“Estimatesoffemale

genitalmutilation/cuttingin27AfricancountriesandYemen”,Studies in Family

Planning,44(2),pp.189-204.

ount

KathrynM.,

2002,“Likemother,likedaughter?Femalegenitalcuttingin

Minia,Egypt”,Journal of Health and Social Behavior,43(3),pp.336-358.

zennerN.,liaoL.-M.,richensY.,creightonS.M.,2013,“Qualityofobstetric

andmidwiferycareforpregnantwomenwhohaveundergonefemalegenitalmutilation”,

Journal of Obstetrics & Gynaecology,33(5),pp.459-462.

Female Genital mutilation. overview and Current KnowledGe

295

Armelle Andro, Marie LesClingand • female genital mutilation. overview and

current knowledge

Female genital mutilation (FGM), which is any form of non-therapeutic intervention leading to the ablation or

alteration of the female genital organs, has adverse health consequences. According to UNICEF, in 2016, more

than 200 million women in the world have undergone FGM. This article examines the prevalence of FGM and its

variation over time in the different regions of the world, and presents current knowledge of the determinants

of the practice and its effects on health and sexuality. Recent public health studies have demonstrated the scale

and diversity of the consequences of FGM, and speciﬁc medical services have been developed for the women

concerned. Available data show that while FGM is well studied in Africa, it remains poorly documented in cer tain

regions of the world. This is notably the case in countries where the practice is clandestine, and in those with

immigrant populations from countries where women undergo FGM.

Armelle Andro, Marie LesClingand • les mutilations génitales féminines. état des

lieux et des connaissances

Les mutilations génitales féminines (MGF), qui désignent toutes les formes d’interventions non thérapeutiques

aboutissant à une ablation ou une altération des organes génitaux féminins, ont des conséquences délétères

sur la santé. En 2016, elles concernent plus de 200millions de femmes et ﬁlles dans le monde selon l’Unicef. Cet

article fait le point sur l’état des connaissances récentes en matière de prévalence de ces pratiques et sur l’état

de la recherche concernant leurs déterminants, leurs conséquences et les enjeux à venir pour favoriser leur

éradication. Les chiffres disponibles montrent que si les MGF sont bien étudiées sur le continent africain, elles

restent mal connues dans certaines régions où elles sont encore des pratiques cachées et dans des pays où elles

sont liées à la mobilité internationale. La typologie des MGF élaborée par l ’OMS a permis de recen ser et d’objectiver

les formes et les conséquences médicales de ces pratiques. Les déterminants de leur perpétuation ou de leur

l’abandon varient selon les régions concernées, et les évolutions restent lentes même si elles sont avérées. Les

études menées récemment en santé publique ont montré l’ampleur et la diversité des séquelles liées à ces

pratiques et elles ont permis le développement de dispositifs de prise en charge médicale des MGF.

Armelle Andro, Marie LesClingand • las mutilaciones genitales femeninas.

estado de la cuestión Y de los conocimientos

Las mutilaciones genitales femeninas (MGF), que designan todas las formas de intervención no terapéuticas que

conducen a una ablación o una alteración de los órganos genitales femeninos, tienen consecuencias perniciosas

para la salud. Según la Unicef, en 2016 este tipo de mutilaciones concernían más de 200 millones de mujeres y

niñas. Este artículo recapitula la prevalencia de dichas prác ticas y su evolución en diferentes regiones del mundo,

y da cuenta de las investigaciones sobre sus determinantes y consecuencias médicas y sexuales. Los estudios

recientes de salud pública han mostrado la importancia y la variedad de las secuelas ligadas a estas prácticas y

han permitido el desarrollo de dispositivos para la atención y el tratamiento médicos de las MGF. Las cifras

disponibles muestran que si las MGF están bien estudiadas en el continente africano, son poco conocidas en

ciertas regiones donde est as mutilaciones son clan destinas y en países conuna migración internacional proveniente

de los países expuestos à las MGF.

Keywords: Femalegenitalmutilation,fe malegenit alc utt ing,gender,violence,sexua lit y,

health,prevalence,demographicsurvey.

TranslatedbyMadeleineGrieveandPaulReeve.

A. Andro, M. LescLingAnd

296

Daughter circumcision and maternal life satisfaction: A cultural moderation effect revealed across two studies

Preprint

Full-text available

Oct 2023

Introduction The present paper explored the relationship between maternal life satisfaction and the intergenerational transmission of female genital cutting (FGC; female circumcision). Methods Across two studies with more than 85,000 participants in 15 countries, maternal surveys reveal that the association is positive and moderated by country-level FGC prevalence. Results Contrary to predictions, in countries in which FGC is uncommon, it is more positively associated with maternal life satisfaction; and in countries in which it is common, it is weakly or negatively associated with maternal life satisfaction. Conclusion Results suggest a diversity of social motives for FGM. Customized messaging to reduce its inter-generational transmission should be considered. KEY MESSAGES What is already known about this topic? Female genital cutting (FGC) has negative implications for health and gender equality and is practiced to different degrees in countries in parts of Africa, Asia, the Middle East, and their diasporas. What this study adds? This study explored the intergenerational transmission of FGC—in particular, how daughter FGC relates to maternal life satisfaction. Contrary to expectations, life satisfaction ratings were higher for mothers of circumcised daughters, although this relationship was moderated by country-level FGC frequency. In countries in which it is more common, daughter FGC is less strongly or negatively associated with maternal life satisfaction. How might this study affect research, practice, or policy? Study findings may inform anti-FGC messaging. In countries in which FGC is common, messaging should highlight its association with relative maternal dissatisfaction. In countries in which it is uncommon, messaging should highlight alternatives to FGC as an expression of cultural identity.

A Robust Cross-Sectional Assessment of the Impacts of COVID-19 Pandemic on the Prevalence of Female Genital Mutilation Among 0–14 Years Old Girls in Nigeria

Preprint

Full-text available

Jan 2025

Background: Female genital mutilation (FGM) is a human rights violation that still affects more than 3 million girls aged 0-14 years each year. To achieve the Sustainable Development Goal 2030 agenda, efforts have been made at the local, national and international levels to end the practice by the year 2030. However, the recent COVID-19 pandemic may have reversed the progress made due to increased rates of early marriage of girls, violence against children and school closures during lockdowns. Although some surveys have examined changes in FGM prevalence over the COVID-19 period, changes at the national and sub-national levels among 0-14 years old girls have not been quantified. Objectives This study aimed to understand the potential impacts of the COVID-19 pandemic on the likelihood of FGM among girls aged 0-14 years, and whether it affected progress towards the elimination of FGM. Design We used Bayesian hierarchical regression models implemented within the integrated nested Laplace Approximations (INLA) frameworks.Methods We modelled the likelihood and prevalence of FGM among girls aged 0-14 years before and after the COVID-19 pandemic in Nigeria, with respect to individual and community-level characteristics, using Bayesian hierarchical models. We used the 2018 Demographic and Health Survey as the pre-COVID-19 period and the 2021 Multiple Indicator Cluster Survey as the post-COVID-19 period. ResultsAt the state level, FGM prevalence varied geographically and increased by 23% and 27% in the northwestern states of Katsina and Kana respectively. There were 11% increase in Kwara and 14% increase in Oyo. However, at the national level the prevalence of FGM was found to decrease from 19.5% to 12.3% between 2018 and 2021. Cultural factors were identified as the key drivers of FGM among 0-14 years old girls in Nigeria. The changes in the likelihood of girls undergoing FGM across the two time periods also varied across ethnic and religious groups following COVID-19 pandemic.Conclusion Our findings highlight that FGM is still a social norm in some states/regions and groups in Nigeria, thereby highlighting the need for a continued but accelerated FGM interventions throughout the country.

Empowering Healthcare Professionals: Unveiling the Harms of Female Circumcision in Malaysia

Book

Dec 2023

This leaflet aims to provide accurate information on the practice of female circumcision in Malaysia to healthcare professionals, with the ultimate objective of bringing about the cessation of this practice within Malaysia.

Prevalence of female genital mutilation and associated factors among daughters aged 0-14 years in sub-Saharan Africa: a multilevel analysis of recent demographic health surveys

Article

Full-text available

Sep 2023

Background Female genital mutilation (FGM) is a harmful traditional practice involving the partial or total removal of external genitalia for non-medical reasons. Despite efforts to eliminate it, more than 200 million women and girls have undergone FGM, and 3 million more undergo this practice annually. Tracking the prevalence of FGM and identifying associated factors are crucial to eliminating the practice. This study aimed to determine the prevalence of FGM and associated factors among daughters aged 0–14 years. Methods The most recent Demographic Health Survey Data (DHS) datasets from sub-Saharan African countries were used for analysis. A multilevel modified Poisson regression analysis model was applied to identify factors associated with FGM. Data management and analysis were performed using STATA-17 software, and the pooled prevalence and adjusted odds ratio (AOR) with a 95% confidence interval (CI) were reported. Statistical significance was set at p ≤ 0.05. Results The study included a weighted sample of 123,362 participants. The pooled prevalence of FGM among daughters aged 0–14 years in sub-Saharan Africa was found to be 22.9% (95% CI: 16.2–29.6). The daughter's place of birth (AOR = 0.54, 95% CI: 0.48–0.62), mother's age (AOR = 1.72, 95% CI: 1.4–2.11), father's education (AOR = 0.92, 95% CI: 0.87–0.98), mother's perception about FGM (AOR = 0.42, 95% CI: 0.35–0.48), FGM as a religious requirement (AOR = 1.23, 95% CI: 1.12–1.35), mother's age at circumcision (AOR = 1.11, 95% CI: 1.01–1.23), residing in rural areas (AOR = 1.12, 95% CI: 1.05–1.19), and community literacy level (AOR = 0.90, 95% CI: 0.83–0.98) were factors associated with FGM. Conclusion The high prevalence of FGM among daughters aged 0–14 years in sub-Saharan Africa indicates the need for intensified efforts to curb this practice. Addressing the associated factors identified in this study through targeted interventions and policy implementation is crucial to eradicate FGM and protect the rights and well-being of girls.

Interactive knowledge transfer with Story Maps on the example of role of women in Ethiopia with a focus on Female Genitale Circumcision (FGC)

Article

May 2025

Comparison of FGM prevalence among Nigerian women aged 15–49 years using two household surveys conducted before and after the COVID-19 pandemic

Article

Full-text available

Jul 2024
BMC PUBLIC HEALTH

Background Due to its economic burden and change of focus, there is no gainsaying of the potential impacts of the COVID-19 pandemic on the progress of several female genital mutilation (FGM) interventions across the various countries. However, the magnitude of the potential changes in likelihood and prevalence should be more accurately explored and quantified using a statistically robust comparative study. In this study, we examined the differences in the likelihood and prevalence of FGM among 15-49 years old women before and after the pandemic in Nigeria. Methods We used advanced Bayesian hierarchical models to analyse post-COVID-19 datasets provided by the Multiple Indicator Cluster Surveys (MICS 2021) and pre-COVID-19 data from the Demographic and Health Surveys (DHS 2018). Results Results indicated that although there was an overall decline in FGM prevalence nationally, heterogeneities exist at state level and at individual-/community-level characteristics. There was a 6.9% increase in prevalence among women who would like FGM to continue within the community. FGM prevalence increased by 18.9% in Nasarawa, while in Kaduna there was nearly 40% decrease. Conclusions Results show that FGM is still a social norm issue in Nigeria and that it may have been exacerbated by the COVID-19 pandemic. The methods, data and outputs from this study would serve to provide accurate statistical evidence required by policymakers for complete eradication of FGM.

Daughter circumcision and maternal life satisfaction: a cultural moderation effect revealed across two multicountry studies

Article

Full-text available

May 2024

Introduction The present paper assessed the relationship between maternal life satisfaction (MLS) and the intergenerational transmission of female genital cutting (FGC, female circumcision). It was hypothesised that the association would be more strongly positive in countries in which FGC is more prevalent (ie, culturally normative), suggesting a practice that is socially reinforcing within sociocultural contexts in which it is common. Methods Across two studies with more than 85 000 participants in 15 African and Asian countries, mothers completed surveys reporting on their own FGC experiences and those of their daughters’ and on their educational history and socioeconomic status. Results The association between MLS and daughter circumcision was weak but positive for the full sample. Contrary to predictions, in countries in which FGC is uncommon, it was more positively associated with MLS, and in countries in which it is common, it was weakly or negatively associated with MLS. Conclusion Results are contrary to the notion that the intergenerational transmission of FGC is a function of happiness deriving from its cultural normativity. They suggest, instead, a diversity of social motives depending on cultural context. Customised messaging to reduce the intergenerational transmission of FGC is discussed.

Violence against Women: Comparing Female Genital Mutilation and Female Circumcision in Malaysia

Article

Full-text available

Nov 2023

The United Nations (UN) General Assembly resolution on 20 December 2012 declared female genital mutilation (FGM) illegal and a violation of women's rights. This declaration was made following the World Health Organization's (WHO) call to eradicate FGM in 1997. The prohibition includes all forms of mutilating, harming, or causing pain to the female genitalia. The female circumcision practice in Malaysia is also categorized as FGM by the United Nations Human Rights (UNHR) at the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) in 2018. In light of these developments, this qualitative study examines and compares the true nature and concepts of FGM and the female circumcision practice from the perspective of Al-Sunnah Al-Nabawiyyah. Documentation was employed for data collection, analysis, and interpretation. The findings reveal a significant divergence between FGM and female circumcision. Female circumcision is more similar to the aesthetic surgery of the female genitalia, known as clitoral hood reduction, which can enhance women's sexuality. In conclusion, female circumcision in Malaysia is not a torturous act that violates women's rights, but rather a safe practice following Islamic law. This study also proposes a comprehensive research initiative aimed at formulating secure and Sharia-compliant protocols for female circumcision.

Bibliography

Chapter

Mar 2025

Clara Chapdelaine-Feliciati

Clara Chapdelaine-Feliciati offers the first comprehensive study of the status of the girl child under international law. This book significantly contributes to bridging two fields usually studied separately: law and semiotics. The author engages in the novel legal semiotics theory to decode the meaning of international treaties (mainly the Convention on the Rights of the Child, Convention on the Elimination of All Forms of Discrimination Against Women, and International Covenants) and assess whether the provisions, as formulated, clearly identify the girl child and take into account the obstacles she faces as a result of sexism, childism, and intersectional discrimination. This is also the first book to apply The Significs Meaning Triad – Sense, Meaning, Significance – in international law, and Semioethics for both a diagnosis and prognosis of problematic signs in view of modifying the wording of relevant treaties.

Prevalence of female genital mutilation and associated factors among women and girls in Africa: a systematic review and meta-analysis

Article

Full-text available

Jan 2024

Background Female genital mutilation (FGM) has zero health benefits. It can lead to short- and long-term risks and complications, including physical, sexual, and mental health and well-being of girls and women. It is a worldwide public health issue with more than 80% prevalence in Africa. It is a global imperative to strengthen work for the elimination, and the United Nations Sustainable Development Goal (SDG) strives to eliminate FGM and monitor the progress made. However, one of a challenge in tracking progress is establishing baseline prevalence data within regions and countries. Therefore, this review aimed to pool the prevalence of FGM in Africa and identify the promoting factors among women and girls. Methods This review was conducted according to the PRISMA checklist guideline. Both published and unpublished studies conducted from 2012 onwards were eligible. Studies written in non-English languages were excluded. To retrieve relevant studies; PubMed/Medline, Google Scholar, Science Direct, African Journals Online databases, and African Index Medicus (AIM) were searched using a combination of searching terms. The Newcastle-Ottawa Assessment Scale (NOS) tool was used to assess the quality of each included study. The Cochran’s Q chi-square and I² statistical tests were used to evaluate the heterogeneity of the included studies. The Funnel plot and Egger's regression test (p value < 0.05) were used to evaluate meh publication bias. We used STATA for analysis and the overall and subgroup pooled effect size was estimated using the random effect model with DerSimonian and Laired pooled effect method. The overall prevalence of FGM and the adjusted odds ratio (AOR) with 95%CI (confidence interval) for contributing factors were calculated and presented using a forest plot. Result This study included 155 primary studies conducted on the prevalence and/or factors associated with FGM in Africa. The pooled prevalence of FGM was 56.4% (95%CI 49.7–63.6). The primary factors promoting the practice of FGM were family history of circumcision (AOR = 13.71, 95%CI 9.11−20.62), being a Muslim religion follower (AOR = 3.51, 95%CI 2.61−4.71), poor wealth index (AOR = 1.38, 95%CI1.27−1.51), higher age (AOR = 2.95, 95%CI 2.49−3.38), not attending formal education (AOR = 3.28, 95%CI 2.62−4.12), and rural residency (AOR = 2.27, 95%CI 1.84−2.80). Conclusion The prevalence of FGM in Africa was found to be high. This study also observed a variation in FGM prevalence across regions and countries and a slight temporal decline over the study period. As the global community enters the final decade dedicated to eliminating FGM, there remains much to be done to achieve the elimination goal.

Circoncision, excision et rapports de domination

Article

Full-text available

Jan 1985

Sylvie Fainzang

6 Women Without Choices: The Debate over Medicalization of Female Genital Cutting and Its Impact on a Northern Kenyan Community

Chapter

Jun 2001

Mutilation génitale féminine et complications de l'accouchement dans la province de Gourma (Burkina Faso)

Article

Dec 2010

titre>Résumé Pour renforcer les activités de lutte contre la mutilation génitale féminine (MGF), cette étude avait pour objectif d’évaluer la prévalence des complications de l’accouchement dues aux MGF dans la province de Gourma, au Burkina Faso. L’étude, transversale, descriptive et analytique, s’est déroulée du 15 juin au 15 août 2007. L’échantillonnage, exhaustif, intégrait l’ensemble des parturientes des quatre maternités de Fada, chef lieu de la Province. L’enquête comprenait un entretien, un examen clinique et une analyse d’archives. Les 354 enquêtées étaient âgées de moins de 25 ans dans 58 % des cas et analphabètes à 78 %. La MGF était de type I, II ou III pour respectivement 28 %, 28 %, et 3 % d’entre elles. Le travail a été dystocique dans 29 % et la césarienne pratiquée dans 7 % des cas. Les accouchements par voie basse comprenaient 24 % d’épisiotomies, 18 % d’hémorragies de la délivrance, 20 % de révisions utérines et 3 % de transfusions sanguines. Parmi les nouveau-nés 5 % ont été réanimés et 4 % mort-nés. L’existence de MGF a augmenté statistiquement la proportion de dystocies (OR = 11,5), de césariennes (OR = 17,6), d’épisiotomies (OR = 6,4), de lâchage de périnées (OR = 10,2), d’hémorragies de la délivrance (OR = 13,0), de révisions utérines (OR = 14,7), de transfusions (OR = 8,0) et de mort-nés (OR = 10,2). Les parturientes avec MGF de type 2 et 3 étaient plus sujettes à la dystocie (OR = 5,7) et à la césarienne (OR = 5,2) que celles avec des MGF de type 1. La MGF constitue un puissant facteur de risque de complications pour l’accouchement. Elle doit être éradiquée pour une bonne santé de la mère, du nouveau-né et de l’enfant au Burkina Faso.

Genitals and ethnicity: the politics of genital modifications

Article

Jan 2010

The discrepancy in societal attitudes toward female genital cosmetic surgery for European women and female genital cutting in primarily African girl children and women raises the following fundamental question. How can it be that extensive genital modifications, including reduction of labial and clitoral tissue, are considered acceptable and perfectly legal in many European countries, while those same societies have legislation making female genital cutting illegal, and the World Health Organization bans even the “pricking” of the female genitals? At present, tensions are obvious as regards the modification of female genitalia, and current legislation and medical practice show inconsistencies in relation to women of different ethnic backgrounds. As regards the right to health, it is questionable both whether genital cosmetic surgery is always free of complications and whether female genital cutting always leads to them. Activists, national policymakers and other stakeholders, including cosmetic genital surgeons, need to be aware of these inconsistencies and find ways to resolve them and adopt non-discriminatory policies. This is not necessarily an issue of either permitting or banning all forms of genital cutting, but about identifying a consistent and coherent stance in which key social values – including protection of children, bodily integrity, bodily autonomy, and equality before the law – are upheld. Résumé Le décalage des attitudes de la société à l'égard de la chirurgie plastique des organes génitaux féminins en Europe et de la mutilation sexuelle féminine principalement chez les fillettes et les femmes africaines conduit à poser une question fondamentale : pourquoi beaucoup de pays européens jugent-ils acceptables et parfaitement légales des modifications génitales poussées, notamment la réduction des lèvres et du clitoris, alors qu'ils interdisent les mutilations sexuelles féminines et que l'Organisation mondiale de la santé proscrit même de « piquer » les organes génitaux féminins ? Présentement, la modification des organes génitaux féminins suscite de toute évidence des tensions, et la législation et la pratique médicale sont contradictoires selon l'origine ethnique des femmes. En ce qui concerne le droit à la santé, on peut se demander si la chirurgie plastique des organes génitaux féminins est toujours exempte de complications et si la mutilation sexuelle féminine s'accompagne toujours de complications. Les militants, les décideurs et d'autres acteurs, dont les chirurgiens plastiques, doivent prendre conscience de ces incohérences et trouver le moyen de les résoudre et d'adopter des politiques non discriminatoires. Il s'agit non pas forcément de permettre ou d'interdire toutes les formes d'incision génitale, mais plutôt d'adopter une position cohérente qui respectera les valeurs sociales, y compris la protection de l'enfance, l'intégrité physique, l'autonomie corporelle et l'égalité devant la loi. Resumen La discrepancia en las actitudes de la sociedad hacia la cirugía cosmética genital femenina en mujeres europeas y la mutilación genital femenina principalmente en niñas y mujeres africanas suscita la siguiente interrogante fundamental. Cómo puede ser que extensas modificaciones genitales, como la reducción del tejido de los labios y el clítoris, se consideren aceptables y perfectamente legales en muchos países europeos, mientras que en esas mismas sociedades existe legislación que penaliza la mutilación genital femenina, y la Organización Mundial de la Salud prohíbe incluso la perforación de los genitales femeninos? Actualmente, las tensiones respecto a la modificación de los genitales femeninos son obvias, y la legislación y prácticas médicas en vigor muestran contradicciones con relación a mujeres de diferentes etnias. En cuanto al derecho a la salud, es cuestionable si la cirugía cosmética genital siempre está libre de complicaciones y si la mutilación genital femenina siempre las causa. Es imperativo que los activistas, formuladores de políticas nacionales y otras partes interesadas, incluso los cirujanos cosméticos, sean conscientes de estas contradicciones, encuentren formas de resolverlas y adopten políticas no discriminatorias. No se trata necesariamente de permitir o prohibir todas las formas de mutilación genital, sino de identificar una postura constante y coherente, que respete importantes valores sociales como la protección de los niños, la integridad corporal, la autonomía corporal y la igualdad ante la ley.

Cutting without ritual and ritual without cutting: Female 'Circumcision' and the ritualisation of initiation in Gambia

Article

Jan 2000

Y. Hernlund

Gender crusades : The female circumcision controversy in cultural perspective

Chapter

Jan 2007

Janice Boddy

Hofriyati cultural models refer to human physiology, like our own, yet their trajectory tends to be elliptical, rather than reductive as is typical in the West. In Hofriyat, biological traits belong to a wider set of motifs that weave through disparate realms of meaning without resolving to essences or absolutes. Enough has been said by now to convey a sense of how villagers' conventional ideas shape their sensibilities, which in turn render their conventions natural, inevitable, real. That the conventions of Western observers are similarly informed-albeit by other priorities and assumptions-should also be clear, granting Western critics no Archimedean leverage on the customs they decry. Moreover, the fact that a society practices female genital cutting cannot be left to "stand for" that society in its entirely-to act as its reductive truth. Clearly, Hofriyati culture is a complex process, often coherent if not always consistent, and as deeply premised as any other. Only when scientists, scholars, and advocates fully embrace these understandings might Western engagement with the practices do less harm than good. As a hint of what may follow should we refuse, I end with a report circulated to a Sudan-focused Internet discussion group, dated June 25, 1998. It is attributed to Nhial Bol, International Press Service, Khartoum, and begins thus: "Sudan's Islamic clerics have urged the people to resist a new campaign by a group of non-governmental organizations in the country to challenge the ageold practice of Female Genital Mutilation (FGM)." The report notes that Sheikh Mohamed Abbas, a respected cleric, has "urged Sudan's 60 percent Moslem community to resist Western culture and to uphold their traditional practices, like FGM"; moreover, it claims that his plea (however conventionally un-Islamic) is backed by some infl uential Muslims in the Islamic state. Tellingly, the censured NGO campaign is local, not foreign-led. When the abolition of female circumcision became a grail in the new crusades, its political reclamation might well have been foretold. This collection copyright

Making mandinga or making muslims? Debating female circumcision, ethnicity, and islam in guinea-bissau and portugal

Chapter

Jan 2007

Michelle C. Johnson

Bafata-Oio, Guinea-Bissau (1997). We fi nish the last round of tea, and everyone leaves but Binta. She and I sit together on a woven mat in the shade of a mango tree. Binta tells me that her eight-year-old daughter has been asking her when she will be circumcised, lamenting that all of her friends have already been through the ritual. Binta smiles and says, "I just tell her to be patient, that you can't rush this thing. When your daughter is circumcised, you have to work hard so you can buy her cowry shells, nice cloth, and food-the girls must have meat in their sauce every day. It's diffi cult, but you just leave it all up to God." I ask Binta to recall the day she was initiated. "I wasn't afraid, and it didn't hurt. When it was all over, I asked the ?amaanoo [traditional circumciser] to cut off the tip of my pointer finger because I didn't feel a thing. To this day, the old woman smiles when she greets me. People say that circumcision is a bad thing for women, but we know the truth. If a woman isn't circumcised, she is unclean and her prayers are worthless. When you are circumcised, you become a true Muslim.". This collection copyright

Réparation du clitoris et reconstruction de la sexualité chez les femmes excisées : la place du plaisir

Article

Oct 2010

Clitoris Repair and the Reconstruction of Female Sexuality after a Genital Mutilation: when Pleasure Becomes an Issue The article analyses the « repair journey » undergone by women who, living in France, have endured female genital mutilation. Through the process, women question the notion of « normality » in relation to their female genital apparatus and, at the same time, the relevance of pleasure in their life experience. In their accounts, women talk about their desire to be « a normal woman ». And surgery may mean for them a real strategy of sexual empowerment, aiming at increasing their capacities and possibilities to be sexually active, thus increasing their sexual agency, and encouraging them to consider their rights to sexuality. The « repair journey » allows them to question « cultural sexual mutilation » present everywhere : in Western culture through speech, images, and more generally in all representations of female sexuality.

La représentativité et les populations difficiles à joindre : le cas des sans-domicile

Chapter

Jan 2012

[Assessment of a multidisciplinary care for 169 excised women with an initial reconstructive surgery project]

Article

Oct 2015

Objective: To assess the benefits of a multidisciplinary care among excised women with an initial surgery project and identify the reasons for discarding surgery. Methods: Descriptive and retrospective study performed between the 1st of January 2006 and the 31st of December 2011 at the Armand Trousseau Hospital, Paris. All excised patients went through consultations with a mid-wife, a sexologist, a psychologist, a gynaecologist-obstetrician and, for some of them, underwent a clitoral reconstructive surgery. Results: One hundred and sixty-nine patients were included: among them, 61 patients (36%) were operated and 108 patients (64%) have given spontaneously to surgery, 32% being reinforced by consultation. Ninety-one on 111 patients (82%) respondents were satisfied with their care pathway. The main motivation was to support identity for 39 patients operated (64%) while improving sex prevailed for 56 non-operated patients (52%). The study evidenced an improvement of the functional and sexual life quality after surgery: 17% experienced an orgasm versus 2% before surgery, 56% reported an increase in their libido and 41% a decrease in dyspareunia. Conclusion: Clitoral reconstructive surgery with multidisciplinary care tends to improve the functional and sexual life quality of excised patients, though it is not always necessary. Some of the patients discard their initial project of reconstructive surgery as in some of the cases, a multidisciplinary care only seems sufficient.

Female genital mutilation. Overview and current knowledge

Abstract

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