The unkindest cut

AT a midwife’s clinic in Jakarta, Indonesia’s capital, services for baby girls include an incision with a needle to the fold of skin above the clitoris. The clinic’s laser, popular with well-off clients, is out of action. Other midwives prefer a needle-prick to draw a drop of blood. Some just dab on iodine. About half of Indonesian girls have had one of these procedures, collectively known as sunat, the local term for ritual female circumcision. Some midwives offer it free as part of their delivery package.

Santinam, a security guard in Jakarta, took his infant girls to a traditional circumciser in the village he comes from. They were not hurt, he says, just cut a little, “nothing even like the way boys are circumcised.” The UN disagrees with his take. It counts such cuts and pricks as female genital mutilation (FGM), even if they cause no lasting harm to health or sexual sensation.

Globally, over 4m girls a year undergo ritual tampering with their genitals, the UN estimates. This ranges from the symbolic, such as rubbing with turmeric or other herbs, through singeing or excising part of the clitoris, to grotesque mutilation (see chart 1). About 400,000 suffer infibulation, in which the vaginal lips and external parts of the clitoris are removed, and the vagina stitched almost closed.

Groups as disparate as the Masai in Kenya, Jews in Ethiopia and Coptic Christians in Egypt practise FGM in some form. Cutting is often done in the name of Islam, even though the Koran does not mention it. It is commonly believed to “tame” a girl’s sexual drive—ensuring that she remains a virgin until marriage and is faithful to her husband. A common myth in Sudan is that an uncut clitoris will grow into a third leg.

FGM is one of the toughest social norms to change because a girl’s marriage prospects depend on it. Many parents know it is harmful but have it done for fear that they or their children will be ostracised. In Djibouti, says Fathia Hassan of UNICEF, the UN’s children’s agency, parents hardly ever admit that their daughter is intact. Research among Somalis living in Sweden found that women were convinced the men favoured infibulation; in fact, men were opposed—but never spoke about it.

The limited data that exist suggest that FGM is becoming less common (see chart 2) and may be shifting to less harmful forms. This is thanks partly to education and urbanisation, and partly to decades of campaigning by the UN and activists publicising the harms. Progress, however, is slow: most girls in Somalia and Djibouti, for example, will probably see their daughters cut, too.

One approach is to try to persuade entire villages to pledge publicly that they are abandoning the practice. In many countries, UNICEF has recruited volunteers to explain the risks to women. Mariam Mohamed is a volunteer in Djibouti. Only the youngest of her four daughters has not been cut, she says. “We had no idea that this was hurting the girls’ health.” But change is slow: the campaign reaches less than 3% of women a year. Many refuse to listen; some take their daughters to Somalia, where no one questions the procedure.

Indonesia’s most senior clerics support sunat. In Bandung, the third-biggest city, an Islamic charity organises group circumcision ceremonies. Elsewhere, religious leaders are increasingly vocally opposed, but their words often fall on deaf ears. In Egypt 61% of girls are cut in defiance of a decade-old fatwa (religious edict) by senior Islamic clerics. Djibouti’s Islamic High Council also plans to issue a fatwa this year, reiterating a statement in 2014. The problem is that, in private, some imams stray from the official line, says Abdurahman Ali, the head of its fatwa department.

In most places FGM is against the law. Though campaigners think that without a shift in attitudes laws can do little, they push for prosecutions to make parents think twice. In Djibouti, though FGM has been illegal since 1995, nearly 80% of women are cut and no cases were brought to court until last year when a circumciser and a mother were given symbolic sentences. Egypt also saw its first court case last year, after a 13-year-old girl died from complications. Her father and the doctor were given prison sentences.

Activists worry that cutting is becoming increasingly medicalised. In Egypt, where the usual practice is to remove part of the clitoris, four-fifths of procedures are now done by doctors; in Sudan over half are done by health workers. Campaigners are partly to blame, says Vivian Fouad, who works on Egypt’s national programme to abolish FGM: for years they intoned that cutting causes deadly infections, which led parents to assume that all is fine if done by a doctor, instead of a traditional circumciser (who, very often, is an old woman with poor eyesight and a rusty blade).

Failure to protect

The survival of FGM despite 30 years of eradication efforts has led some to suggest a different strategy: focusing on the types that cause long-term harm and permitting the rest, if carried out by medical personnel. But every time the idea is raised, it is scuppered by a storm of outrage.

The debate goes back at least 20 years. In 1996 a doctor in Seattle’s Harborview Hospital asked a pregnant woman, a recent immigrant from Somalia, a routine question about her labour and delivery plans: did she want the baby circumcised if a boy. “Yes,” she said, “and also if it’s a girl.” After discussions with local Somali parents, the hospital decided to offer a ritual nick—to avoid greater harm if the parents looked elsewhere. But after widespread criticism, it withdrew the offer.

In 2004 a similar attempt by a hospital in Florence met the same fate. In 2010 the American Academy of Paediatrics supported Harborview’s approach—only to retract less than a month later. Similarly, Indonesia has issued and then withdrawn guidelines for doctors.

The latest row is about a paper published earlier this year in the Journal of Medical Ethics. The authors, gynaecologists Kavita Arora and Allan Jacobs, argue that some types of cutting, such as those common in Indonesia, do not harm physical functioning and should not be described as “mutilation”. Some, they say, are less invasive than male circumcision, which is near-ubiquitous in America (see article); others, though more severe, resemble labiaplasty, a surgical reduction of the vaginal lips that some Western women undergo for cosmetic reasons. Applying the “yuk factor” to all pricks and cuts is unhelpful, says Dr Arora. If even a few parents switched from major to minor forms of cutting, great suffering would be averted.

Nafissatou Diop of UNFPA, the UN’s population agency, disagrees. Accepting cutting by doctors would grant spurious respectability to all forms of FGM, she says. And the agency knows of girls who have already been cut being subjected to further mutilation at the insistence of relatives unsatisfied with the initial result.

In Indonesia, opinions on whether the practice should be regulated are split. In 2010, pressed by Islamic organisations that lobbied for medicalisation to prevent infections, the health ministry issued guidelines telling doctors to give a light scratch to the skin covering the clitoris. Four years later, under pressure from anti-FGM activists, it withdrew the guidelines but stopped short of a ban. Eni Gustina, of its family-health department, doubts that a ban can achieve much while sunat is such a popular tradition. But guidelines, she says, may distract health workers from pressing the message that sunat has no health benefits.

Emi Nurjasmi of the Indonesian midwives’ association sees things differently. The methods used by midwives vary, she says, because the procedure is not taught in midwifery school and there is no official standard. The association tells midwives to advise mothers against sunat and, if pressed, to dab the genitals with iodine.

The issue is becoming ever more urgent in the West, as rising numbers of immigrants arrive from places where FGM is common. Some girls are taken to their countries of origin for the procedure; school holidays have been dubbed “the cutting season”. There is no easy way to protect all girls from the custom. But redrawing the line to separate the harmless and atrocious might help.