Female Circumcision:

The History, the Current Prevalence and the Approach to a Patient

Jewel Llamas
April 2017

Introduction
media, travel and international migration,
Female circumcision, also known as female widespread awareness (beyond the regions of its
genital mutilation (FGM) or female genital cutting practice) of the history and beliefs that perpetuate
(FGC), is practiced in many countries spanning this tradition is essential. This paper offers a guide
parts of Africa, the Middle East and Southeast Asia. to help practitioners understand the terminology,
Over 100 million women and young girls living classifications, origin, proposed purposes, current
today have experienced some form of FGM with distribution and prevalence of FGM, closing with
millions more being affected annually. With the recommendations for obtaining a history from and
world becoming a smaller and smaller place via conducting a pelvic exam on this patient population.

Terminology and Classifications

The practice of female genital alterations has procedures involving partial or total removal of the
been referred to by many different names. The external genitalia or other injury to the female
United Nations conducted their earliest studies on genital organs for non-medical reasons.”3
these practices using an anthropological approach, With the establishment of its internationally-
adopting the term “female circumcision,” which the accepted definition came the differentiation of four
World Health Organization adopted as well. separate types, or severities, of FGM seen in
However, many believed this term euthanized and practice:
“normalized” the practice, making it comparable to  Type 1: Only Prepuce removal or
prepuce removal plus partial or total
removal of the clitoris (also referred to
as clitoridectomy)
 Type 2: Removal of the clitoris plus a
portion of or all of the labia minora
(excision)
 Type 3: Removal of a portion of or all of
the labia minora with the labia majora
being sewn together, covering the
urethra and vagina and leaving small
opening for urination and menstruation
(infibulation)
 Type 4: All other harmful procedures to
widely accepted male circumcisions. In the mid the female genitalia for non-medical
1970s, feminist activists of the time emphasized the purposes including pricking, piercing,
harmful consequences this tradition could have on incising, scraping and cauterizing
its recipients. Accordingly, to recognize the damage
done to normal, healthy tissue, they began using the However, this terminology is not accepted by
term “mutilation” versus “circumcision.”1 Since the all, especially by those who originate from areas
1990s, “female genital mutilation” (FGM) has been where these practices occur. In one ethnographic
widely accepted.2 Its current formal definition is “all study conducted in Sudan, participants often found
the term “mutilation” offensive, suggesting
1
“intentional harm” and “evil intent.” These used but only one will be suggested for patient
participants preferred the term “female interactions.
circumcision.”2 In this paper, both terms will be

Origin of the Practice

Location implemented on female slaves in Ancient Rome,

deterring recipients from coitus and subsequent
The exact origin of female genital mutilation pregnancy. 1
(FGM) remains unclear. Some scholars have With its widespread prevalence, a “multi-source
proposed Ancient Egypt (present-day Sudan and origin” has also been proposed, claiming that FGM
Egypt) as its site of origin, noting the discovery of spread from “original cores” by merging with pre-
circumcised mummies from fifth century BC. Other existing initiation rituals for men and women.4
scholars theorize that the practice spread across the Despite the perplexity surrounding its origin, the
routes of the slave trade, extending from the practice of FGM endears across the globe, serving
western shore of the Red Sea to the southern, several theoretical purposes for the communities
western African regions, or spread from the Middle that propagate its practice.
to Africa via Arab traders.1,4 The practice was also

Figure 2. Geographic Distribution of Female Genital Mutilation7

“sexual propriety” and “morality,” “demonstrating

Proposed Purposes of FGM the obedience and respect required for
marriageability.” 4 In the highly structured social
For the regions where FGM originated, scholars framework of the ancient Egyptian empires, FGM
have proposed three functions for this practice. The was implemented as a means of perpetuating
first draws from the theories behind the inequality between the classes, with families cutting
“marriageability” of a woman, emphasizing the young girls and women, signifying their
ideologies of “virginity, purity, and sexual restraint” commitment to the wealthy, polygamous men of
that are upheld in the societies where FGM is their society. 4
practiced. By reducing (or increasing, depending However, female circumcision is practiced
on the cultural group) sexual pleasure, the today in areas where female premarital sexual
procedure protects young girl’s and women’s intercourse is permitted, such as the Rendille
2
women of Kenya. In such areas, the practice is it from contact with the penis, doctors removed the
thought to serve its second proposed purpose: a adhesions between the clitoris and its hood or
means of solidifying ones “cultural identity” and removed its hood completely. According to
transition to being an “adult member of society.” gynecologist, Dr. Howard Kelly of Johns Hopkins
For example, the name of the “Kipsigis” of Kenya University, the adhesions between the clitoris and
translates to “we the circumcised,” as, after hood were also believed to cause “irritation,”
circumcision, one is thought to be “reborn.”4 In leading to masturbation. If proficient cleaning was
areas where FGM is a tradition, parents fear their insufficient treatment, circumcision was deemed an
daughter will be banned from their society.5 appropriate alternative treatment.6
Its third possible function surrounds the idea of Table 1. Female Genital Mutilation
protecting the health of women and their fetus. In Prevalence among Girls 0 to 14 Years of Age7
some cultures, FGM is believed to improve hygiene Country Prevalence (%)
and increase a woman’s probability of conception Gambia 56
with intercourse. In addition, physical contact Mauritania 54
between the “toxic” clitoris and a baby during Indonesia 49
childbirth is thought to be potentially fatal to the Guinea 46
fetus.4 The procedure also conserves the recipient’s Eritrea 33
attractiveness, as the clitoris could potentially grow
Sudan 32
until it “touches the ground.”5
Guinea-Bissau 30
Cases of female genital mutilation were reported
Ethiopia 24
for centuries in European countries as well. Interest
Nigeria 17
in the practice grew in the 1860s when Isaac Baker
Brown –the founder of the London Surgical Home Egypt 14
for Women –noted that female epileptics in his Burkina Faso 13
hospital tended to masturbate. From this Senegal 13
observation, he concluded that masturbation led to Côte d'Ivoire 10
hysteria, then epilepsy and subsequent “idiocy and Kenya 3
death.” Brown believed the only cure for this path Central African Republic 1
to “feminine weakness” and death was Ghana 1
clitoridectomy, which gained widespread Uganda 1
acceptance.2 Togo 0.3
In the late nineteenth century, in Western Benin 0.2
cultures its primary function unfolded to become a
means of regulating certain sexual practices
After analyzing these practices of
(particularly female masturbation, “hysteria,” and
American obstetricians that extended as late
lesbianism) and clitoral enlargement.1,5
as the 1960s, Sarah Rodriguez concluded
Masturbation was seen as a disorder with treatment
Western practices of FGM emphasized the
being reserved for its most severe cases. In 1896,
need to control female sexuality and align its
for a twenty-nine year old, single female living in
with a purpose beyond women’s own
Brooklyn, New York, this meant obtaining a
desires: the purpose of contraception and
clitoridectomy when her concerned father told their
wifely duties.6 American physicians’
doctor, Dr. John Polak, about her acts of
rationale for FGM closely mirrored the
masturbation twenty to forty times a day.
values of hygiene, purity, sexual restraint,
In the late nineteenth century, a wife’s failure to
and marital commitment that brought FGM
enjoy coitus with her husband was also seen as
to existence thousands of years
evidence of a disorder in Western culture. Thought
to be secondary to the hood of the clitoris separating

3
 of female genital mutilation .7 Two million more
Table 2. Female Genital Mutilation Prevalence females are considered at risk of undergoing FGM
among annually.2 Young girls typically undergo FGM prior
Girls and Women 15 to 49 Years of Age7 to puberty, between six and twelve years of age.
Country Prevalence (%) In some cultures, the procedure may be performed
Somalia 98 at birth, at menarche or prior to marriage.5
Guinea 97 The prevalence of the four different types of
Djibouti 93 FGM varies geographically. Type I is mostly
Sierra Leone 90 practiced in Ethiopia, Eritrea and Kenya; Type II, in
Mali 89 regions of West Africa such as Benin, Sierra Leone,
Egypt 87 Gambia and Guinea; Type III, in Somalia, Northern
Sudan 87 Sudan, eastern Chad, southern Egypt, and Djibouti
Eritrea 83 and Type IV in Northern Nigeria.2,5 Eighty percent
Burkina Faso 76 of Type III, the most severe type, occurs in
Gambia 75 Somalia.2 According to UNICEF’s global databases
Ethiopia 74 of 2016, the practice of FGM on girls up to fourteen
Mauritania 69 years old is most prevalent in Gambia (56% of the
Liberia 50 age group), Mauritania (54%) and Indonesia (49%)
Guinea-Bissau 45 (Table 1).7 Among 15 to 49 year old females, FGM
Chad 44 is mostly heavily practiced in Somalia (98%),
Côte d'Ivoire 38 Guinea (97%) and Djibouti (93%) (Table 2).7
Nigeria 25 Midwives or trained circumcisers travel across
Senegal 25 several villages, conducting the surgery without
Central African Republic 24 anesthesia, antibiotics or sterile equipment.5
Kenya 21 Although the majority of women in many of these
Yemen 19 countries now believe the practice should be ended,
United Republic of Tanzania 15
some still believe in the tradition. Further
Benin 9
complicating efforts for its global eradication, the
Iraq 8
majority of girls and women in Guinea (76%), Mali
Togo 5
(73%), Sierra Leone (69%), Somalia (65%) and
Ghana 4
Egypt (54%) still support the tradition (Table 3).7
Niger 2
With the persistent practice of female
Cameroon 1
circumcision and the increase of international
Uganda 1
migration, awareness outside of the realms of its
The State of the Practice Today practice is essential in order to provide these women
with proper, culturally-sensitive care.
Advances in medicine disproving the beliefs
Approach to a Patient with a History of Female
behind FGM in Western Culture, many cultures
Circumcision
now denouncing the practice due to advances in
women’s rights, the United Nations General
Obtaining a History
Assembly adopting a ban of female genital
When an immigrant or refugee settles in a new
mutilation in December of 2012—despite all of
country, a general practitioner is often the first
these factors, this practice still persists in twenty-
medical provider they see. Nonetheless, many
nine countries spanning Africa, parts of the Middle
obstacles can impede a physician’s ability to
East and Southeast Asia (Yemen, Iraq, Indonesia
identify a woman or child’s history of female
and Malaysia) (Figure 2).1 Today, more than 125
circumcision. Firstly, the provider must be aware of
million girls and women have suffered some form
its risk factors: lineage to a community known to
4
practice FGM or a first- or second-degree, female of origin. In the Democratic Republic of Congo
relative with a history of the procedure. Secondly, (DRC) (where the patient who ignited my interest in
the practitioner must feel comfortable asking the FGM was from), forty percent of women and
patient about female circumcision. As the lower twenty-four percent of men have suffered some
types of FGM may be more difficulty to identify on form of sexual violence. One study stated that
physical exam, especially by more inexperienced approximately forty-eight women are raped every
physicians, it is important to ask prior to hour in the DRC.8
examination.3 Furthermore, if the examiner does While some women may spontaneously share
first recognize a history of FGM on exam and their history of sexual violence, others may be more
appears alarmed or upset, this can be demoralizing reluctant to share such sensitive information,
to the patient.9 especially at a first visit. Nonetheless, surveys have
As previous studies have shown that the term shown that the majority of women with a history of
“female genital mutilation” may offend some sexual trauma prefer routine inquiries versus having
patients, I recommend referring to the practice as to mention the topic themselves.9 Accordingly,
“female circumcision.” If a woman does have a asking about a history of sexual abuse is
history of female circumcision, their chance of recommended, particularly with women who have
having experienced another form of sexual violence not had routine pelvic examinations in the past or
may also be increased, depending on their country appear more distressed than normal.

Table 3. Support for the Continuation of Female Genital

Mutilation Among 15-49 Year Old Girls and Women7

Country Percentage of Support

Guinea 76
Mali 73
Sierra Leone 69
Gambia 65
Somalia 65
Egypt 54
Mauritania 41
Sudan 41
Liberia 39
Chad 38
Djibouti 37
Ethiopia 31
Nigeria 23
Yemen 19
Senegal 16
Côte d'Ivoire 14
Guinea-Bissau 13
Eritrea 12
Central African Republic 11
Burkina Faso 9
Uganda 9
Cameroon 7
Kenya 6
Niger 6
United Republic of Tanzania 6
Iraq 5
Benin 3
Ghana 2
Togo 1

5
 While obtaining a patient’s history, physicians from unsanitary equipment, dyspareunia,
must also inquire about a number of possible anorgasmia or complications with pregnancy and
immediate and long-term complications of the childbirth.3
various types of FGM. Due to the psychological effects of dyspareunia
Immediate side effects of FGM include pain, and the anatomic scarring from the procedure, thirty
infection, hemorrhage, emotional and physical percent of women who undergo infibulation (Type
shock, and damage to approximating organs, such III of FGM) are infertile. If a patient does become
as the urethra or bowel.3 If the urethral or vaginal pregnant, infibulation increases her chance of many
openings are obstructed, the patient may develop obstetric complications: postpartum hemorrhage,
urinary retention, amenorrhea, dysmenorrhea or episiotomy, vesicovaginal fistula, cesarean delivery,
other subsequent problems.2 Long-term sequelae of extended hospital stay, stillbirth and neonatal
the procedure could include chronic vaginal death.5, 2
infections, chronic urinary tract infections resulting
in scarring and impaired renal function, blood-born
viral infections (HIV, Hepatitis B or hepatitis C)

Approach to the Pelvic Exam

not want the patient to be surprised and ultimately
According to the Women’s Preventative feel violated, diminishing patient-physician trust.
Services Guidelines, during a routine, preventive This also gives the patient the opportunity to
women’s health evaluation, women should be express concerns or decline portions of the exam, if
screened routinely for cervical cancer, sexually she so desires. Her expression of her concerns allots
transmitted infections, and domestic or the provider another opportunity to elaborate on
interpersonal violence.10 Many of these components aspects of exam that make the patient feel most
of the visit may make any patient feel uncomfortable.
uncomfortable and vulnerable. For women with Even with proper education and consent,
history of FGM or sexual trauma, pelvic speculum and digital examination may still awaken
examination could be particularly distressing. flashbacks of their trauma, igniting anxiety and fear
Considering this truth, Bates et al. of the before, during and after the procedure.
Department of Obstetrics and Gynecology at Beth “Dissociation” during the exam may occur while
Israel Deaconess Medical Center of Boston, examining victims of trauma. Signs of this include
Massachusetts, sought to analyze all of the developing a childlike voice or having a “startle
components the pelvic exam, delineating techniques response” to noises in the room or clinic. If this
for minimizing discomfort and optimizing occurs, the exam should be stopped and the patient,
culturally-sensitive care.9 once reoriented, should be offered mental health
Firstly, to avoid placing a patient in a vulnerable resources. 9
position prior to obtaining consent, they suggest If the patient has had infibulation, pelvic
conducting patient education while the patient is examination may be physically impossible or
sitting upright and still fully clothed.9 Because of significantly painful for the patient, due to scarring
the increased vulnerability of this population, taking with secondary vaginal and introital stenosis. In
extra time to fully explain the components of the such cases, the patient should be referred to a
exam in the patient’s preferred language (using an gynecologist with experience working with this
interpreter, if indicated) is essential, as one would population, if possible. 9 A full outline of
recommendations is provided in Appendix A.

Conclusion
identity of twenty-nine nations worldwide, affecting
Female genital mutilation and circumcision is a millions of young girls and women every year. With
tradition embedded deeply in the culture and the significant number of immigrants and refugees
6
in the United States, one’s probability of seeing a must be spread, assuring that knowledgeable,
patient who has undergone some type of FGM is empathetic, culturally-sensitive care is provided to
not insignificant. Accordingly, more awareness of this potentially vulnerable population.
the complex history and complications of FGM

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Appendix A10: