This comprehensive article, titled “Female Genital Mutilation and Cutting: An Anatomical Review and Alternative Rites,” authored by Vincenzo Puppo and published in Clinical Anatomy in 2017, provides a detailed review of Female Genital Mutilation/Cutting (FGM/C). The paper thoroughly defines FGM/C, outlines its various classifications and profound complications, and critically examines intervention strategies aimed at its abandonment, particularly focusing on Alternative Rites of Passage (ARPs).
The article highlights several key aspects of FGM/C:
- Definition and Scope: FGM/C is defined as any procedure involving partial or total removal of the external female genitalia or other injury to these organs for non-medical reasons. The World Health Organization (WHO) considers it a violation of the human rights of children and women, often performed without informed consent or under coercion, and without medical benefit.
- Prevalence and Context: Over 200 million women alive today have been subjected to FGM/C worldwide, with three million girls continuing to be at risk each year. It is prevalent in 30 countries across Africa, and in some parts of Asia and the Middle East, with cases also reported among certain ethnic groups in Central and South America and in developed countries due to migration. The practice is primarily a cultural tradition rather than a religious one, though religious interpretations are sometimes used to justify it. It is seen as a rite of passage from girlhood to womanhood, conferring social status and ensuring perceived chastity. The procedures are typically carried out by older female traditional cutters, often without anesthesia, using instruments like knives, scissors, or razors.
- Anatomical Review and Classification:
- The article provides an anatomical description of the vulva, emphasizing that the clitoris is entirely an external genital organ and that orgasm is always possible if female erectile organs are effectively stimulated, regardless of the vagina’s lack of anatomical relationship with the clitoris. This anatomical understanding is deemed essential for women’s sexual health.
- The WHO classifies FGM/C into four types:
- Type I: Involves removal of the prepuce only (circumcision) or removal of the clitoris with the prepuce (clitoridectomy), where all or part of the clitoral body is cut.
- Type II: Ranges from removal of the labia minora only to partial or total removal of the clitoris, labia minora, and labia majora. Scarring can sometimes lead to the closure of the vaginal orifice.
- Type III (Infibulation): This is the narrowing of the vaginal orifice by cutting and appositioning the labia minora and/or labia majora, with or without clitoris removal, creating a covering seal of skin from scar tissue that can cover the clitoris and urethra. Reinfibulation is a procedure to recreate this state, often after childbirth or to restore a “virginal appearance”.
- Type IV: Encompasses all other harmful procedures on female genitals for non-medical purposes, including piercing, incision, scraping, pricking, and the controversial elongation (stretching) of the labia minora (known as the “Hottentot apron”), which is considered a permanent genital change. The article also argues that Female Genital Cosmetic Surgery (FGCS) should be classified as FGM/C Type IV, noting that anatomically, there is little to distinguish FGM from many FGCS procedures like “vaginal rejuvenation” or “designer vaginoplasty”. Such cosmetic procedures are not medically indicated and lack documented safety and effectiveness.
- Complications: FGM/C is associated with a wide range of severe complications:
- Immediate: Extreme pain, hemorrhage, shock, difficulty passing urine, infection, sepsis, increased risk of HIV transmission due to unsterile instruments, psychological consequences, and even death.
- Long-term: Chronic pain, cysts, genital ulcers, chronic pelvic infections, renal failure, septicemia, keloid formation, vesico-vaginal or recto-vaginal fistulae leading to incontinence, vaginal obstruction, menstrual problems, urinary issues, sexually transmitted infections, painful sexual intercourse and sexual dysfunctions, infertility, post-traumatic stress disorder, anxiety, depression, and higher obstetric complications like cesarean sections, post-partum hemorrhage, and danger to newborns.
- Psychological Impact: Women who migrate to Western countries often experience significant psychological distress, including feelings of humiliation, powerlessness, and shame, upon realizing that FGM/C is not a universal tradition and that they are considered “mutilated”.
- Intervention Strategies and Alternative Rites of Passage (ARPs):
- Recognizing FGM/C as a human rights violation, the international community, including the United Nations, is working towards its eradication.
- The article strongly advocates for Alternative Rites of Passage (ARPs) as a crucial strategy. ARPs involve maintaining the cultural celebration of a girl’s transition to womanhood but without genital cutting. These rituals often include educating girls about family life, women’s roles, sexual and reproductive health, gift exchange, and a public declaration for community recognition.
- Successful ARP models have been implemented in communities such as the Maasai and Samburu in Kenya and Tanzania, where organizations like Amref Health Africa have worked with elders, leading to thousands of girls graduating through ARPs and avoiding FGM/C.
- The author also proposes a “symbolic pricking” on the mons pubis (not the genitalia) as a less invasive alternative for families at high risk of FGM/C when other educational strategies fail, considering it preferable to more severe mutilations.
- The article emphasizes the importance of involving men in discussions and campaigns to abandon FGM/C, as they play a crucial role in family decision-making and can help challenge false beliefs about sexual pleasure associated with the practice.
- Furthermore, a multidisciplinary approach to healthcare is recommended for prevention and care, involving various medical professionals such as gynecologists, urologists, sexologists, pediatricians, psychologists, and social workers.
In conclusion, the article stresses that FGM/C is a human rights violation that must be abandoned, and that Alternative Rites of Passage offer a viable, culturally sensitive pathway to achieve this goal. It underscores that eradication is a collective effort requiring cultural change, legal sanctions, public discourse, and dedicated medical support.
Reference: Puppo, V. (2017). Female genital mutilation and cutting: An anatomical review and alternative rites. Clinical Anatomy, 30(1), 81–88. https://doi.org/10.1002/ca.22763
